A 60-year-old professor is brought to the emergency department after developing right-sided weakness and numbness during a lecture an hour ago. He also has nausea and confusion. The patient smoked a pack of cigarettes daily for 20 years but quit 10 years ago. He does not drink alcohol. His father died of myocardial infarction at age 70. Blood pressure is 190/100 mm Hg, and pulse is 60 /min. On physical examination, there are no signs of head trauma. There is diminished right-sided strength (1/5) and an upgoing plantar reflex. Brain CT without contrast is obtained immediately. The image is shown below. Which of the following is the most likely cause of this patient's condition?

Question

A 60-year-old professor is brought to the emergency department after developing right-sided weakness and numbness during a lecture an hour ago.  He also has nausea and confusion.  The patient smoked a pack of cigarettes daily for 20 years but quit 10 years ago.  He does not drink alcohol.  His father died of myocardial infarction at age 70.  Blood pressure is 190/100 mm Hg, and pulse is 60 /min.  On physical examination, there are no signs of head trauma.  There is diminished right-sided strength (1/5) and an upgoing plantar reflex.  Brain CT without contrast is obtained immediately.  The image is shown below.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_39c2_517e_9249_d3f58d38f500_MD0001_00 This patient's brain CT is diagnostic for acute hypertensive intracerebral hemorrhage of the thalamus. Hypertensive vasculopathy involving the small penetrating branches of the cerebral arteries is the most common cause of deep intracranial hemorrhage. Chronic hypertension can lead to progressive arteriolar hyalinization and fibrinoid necrosis, weakening the vessel wall and predisposing to the formation of Charcot-Bouchard aneurysms. Aneurysmal rupture may ultimately lead to hemorrhage within the brain. The most common sites of intracranial hemorrhage are deep brain structures, such as the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. Acute neurologic deficits can vary depending on hemorrhage location. This patient's contralateral weakness/numbness and extensor plantar response is consistent with thalamic hemorrhage with edema/mass effect on the internal capsule. Symptoms may worsen within minutes to hours and can be associated with headache, nausea/vomiting, or decreased level of consciousness as the hematoma expands. Acute bleeding appears as hyperattenuated, or bright, lesions on noncontrast head CT. (Choices A) Arteriovenous malformations are the most common cause of intracranial hemorrhage in children. This patient's older age makes the diagnosis less likely. (Choices B and C) Carotid artery atherosclerosis and cardiac embolism are 2 common causes of ischemic stroke. Clinical presentation may resemble hemorrhagic stroke; however, this patient's CT findings are consistent with hemorrhage. Spontaneous hemorrhagic transformation of ischemic stroke would be rare within hours of symptom onset. (Choice D) Cerebral amyloid angiopathy is the most common cause of lobar/cortical parenchymal hemorrhage, particularly in older adults. This patient's deep intracranial hemorrhage makes hypertensive vasculopathy more likely. (Choice F) Hypertensive encephalopathy is characterized by a progressive headache and nausea/vomiting followed by nonlocalizing neurologic symptoms (eg, confusion). This patient's focal neurologic deficits and evidence of hemorrhage on CT exclude this diagnosis. (Choice G) Hypoxic encephalopathy is caused by decreased oxygenation of the blood (eg, due to cardiac arrest). It most often presents with decreased consciousness (eg, coma or vegetative state); focal neurologic deficits and intracranial hemorrhage would not be seen. (Choice H) Intracranial vasculitis can lead to intraparenchymal hemorrhage but is a far less common etiology compared to hypertensive vasculopathy. (Choice I) Saccular aneurysm rupture is typically associated with subarachnoid hemorrhage as opposed to intraparenchymal hematoma. Patients usually have an abrupt onset of severe headache (thunderclap headache), and focal neurologic deficits are less common. On CT, subarachnoid hemorrhage appears as hyperattenuation of the sulci and basal cisterns. Educational objective: Deep intraparenchymal hemorrhage is most commonly caused by hypertensive vasculopathy of the small penetrating branches of the cerebral arteries (Charcot-Bouchard aneurysm rupture). This is in contrast to rupture of saccular aneurysms, which typically cause subarachnoid hemorrhage. __________ References: Primary intracerebral hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/16769513) Fibrinoid necrosis of small brain arteries and arterioles and miliary aneurysms as causes of hypertensive hemorrhage: a critical reappraisal. (http://www.ncbi.nlm.nih.gov/pubmed/18642006)

A 60-Year-Old Professor Is Brought to the Emergency Department After