A 56-year-old man comes to the emergency department an hour after acute onset of right-sided weakness and numbness. His symptoms progressed over a course of several minutes, and he is now experiencing nausea and headache. The patient has not seen a physician for many years and takes no medications. He has smoked a half pack of cigarettes per day for 32 years. Blood pressure is 170/90 mm Hg and pulse is 88/min. Physical examination shows 3/5 muscle strength and hyperreflexia in the right upper and lower extremities. Sensation to pinprick and light touch is decreased on the right side. He has mild dysarthria. ECG shows normal sinus rhythm and left ventricular hypertrophy. Fingerstick blood glucose is 130 mg/dL and serum LDL is 142 mg/dL. Noncontrast head CT scan is shown below. Which of the following is the most likely cause of this patient's symptoms?

Question

A 56-year-old man comes to the emergency department an hour after acute onset of right-sided weakness and numbness.  His symptoms progressed over a course of several minutes, and he is now experiencing nausea and headache.  The patient has not seen a physician for many years and takes no medications.  He has smoked a half pack of cigarettes per day for 32 years.  Blood pressure is 170/90 mm Hg and pulse is 88/min.  Physical examination shows 3/5 muscle strength and hyperreflexia in the right upper and lower extremities.  Sensation to pinprick and light touch is decreased on the right side.  He has mild dysarthria.  ECG shows normal sinus rhythm and left ventricular hypertrophy.  Fingerstick blood glucose is 130 mg/dL and serum LDL is 142 mg/dL.  Noncontrast head CT scan is shown below.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d55a_1463_bc81_99b45ff40867_MD0003_00 This patient has an acute left basal ganglia (putaminal) hemorrhage. Intraparenchymal brain hemorrhages typically present with sudden focal neurologic deficits that gradually worsen over minutes to hours. Putaminal hemorrhage almost always involves the adjacent internal capsule, leading to contralateral hemiparesis and hemianesthesia due to disruption of the corticospinal and somatosensory fibers in the posterior limb. As the hemorrhage expands, headache, nausea/vomiting, and altered mental status can develop due to elevated intracranial pressure. Acute hemorrhage appears hyperdense on noncontrast head CT scan. Hypertensive vasculopathy involving the small penetrating branches of the major cerebral arteries is the most common cause of spontaneous deep intracerebral hemorrhage. Chronic hypertension leads to the formation of Charcot-Bouchard aneurysms, which may rupture and bleed within the deep brain structures. The most frequently affected locations include the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. The basal ganglia are supplied by the lenticulostriate arteries (small vessel branches from the middle cerebral artery). basal ganglia (putamen) (Choice A) Cerebral amyloid angiopathy is the most common cause of spontaneous lobar/cortical hemorrhage (eg, occipital, parietal) in the elderly (age >60). lobar/cortical hemorrhage (Choice B) Brain arteriovenous malformation is the most common cause of intraparenchymal brain hemorrhage in children. arteriovenous malformation (Choice C) Ruptured berry aneurysms cause subarachnoid hemorrhage, which is characterized by the abrupt onset of severe (thunderclap) headache and hyperattenuation of the sulci and basal cisterns on head CT. Focal neurologic deficits are uncommon. subarachnoid hemorrhage (Choice D) Carotid artery atherosclerosis with thrombosis or embolism can cause ischemic stroke, which may undergo hemorrhagic transformation. Embolic strokes are more likely to bleed than thrombotic strokes; however, they typically involve the cortical/lobar regions of the brain and affect multiple vascular distributions. (Choice E) Cerebral venous thrombosis typically occurs in patients with hypercoagulable conditions (eg, contraceptive use, malignancy) and can present with headache, altered mentation, seizures, and focal neurologic deficits. The diagnosis is confirmed using MRI of the brain with venography as head CT scan often shows no abnormalities. (Choice G) Meningeal artery tears typically occur due to traumatic head injury and result in epidural hematoma. Patients may have altered consciousness, headache, nausea/vomiting, and focal neurologic deficits; however, head CT scan typically shows acute hemorrhage in a biconvex pattern that does not cross suture lines. epidural hematoma (Choice H) Brain metastases (eg, from lung, breast, or kidney carcinoma) may be complicated by intratumoral hemorrhage; however, metastatic brain lesions typically appear as multiple circumscribed lesions at the grey-white junction. Brain metastases (Choice I) Subdural hematomas result from traumatic tearing of the bridging veins. Patients can have headache, altered mentation, seizures, and/or focal neurologic deficits; however, noncontrast head CT scan classically reveals a crescent-shaped hemorrhage that crosses suture lines. Subdural hematomas Educational objective: Spontaneous deep intracerebral hemorrhage is typically caused by hypertensive vasculopathy involving the penetrating branches of the major cerebral arteries. Common locations include the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. Putaminal hemorrhage often produces contralateral hemiparesis and contralateral sensory loss due to injury of the adjacent internal capsule. References: Intracranial hemorrhage: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/22284061) Intracranial hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/22974648)

A 56-Year-Old Man Comes to the Emergency Department an Hour