Stroke: Hypertensive haemorrhage – radiology video tutorial (MRI, CT)
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Stroke: Hypertensive haemorrhage – radiology video tutorial (MRI, CT)

September 8, 2019


Hello, I’m Frank Gaillard from radiopaedia.org and today we are going to talk about hypertensive haemorrhages. intracranial hemorrhages have
traditionally been divided into primary and secondary. With primary haemorrhages being further
subdivided into those due to chronic poorly-controlled hypertension and lobar haemorrhages. Secondary hemorrhages typically
are those that arise from an underlying tumour, a vascular malformation or hemorrhagic
transformation of a previous ischaemic infarct or of a venous infarct. in reality both hypertensive and lobar haemorrhages do have underlying pathology making the distinction between
primary and secondary haemorrhages somewhat academic. Intracranial hemorrhages can also be
divided according to location. Generally there are though of as lobar
hemorrhages located within the cerebral lobes superficially, basal ganglia hemorrhages arising from
from the grey matter of the basal ganglia and thalamus, pontine haemorrhages, and cerebellar hemisphere haemorrhages. it is the latter three that we will be
discussing today as all three are associated with chronic poorly-controlled hypertension. approximately eighty percent of
hypertensive haemorrhages arise from the basal ganglia and thalami, with a further ten percent from the pons, and the remaining ten percent from the
cerebellar hemispheres. this distribution correlates with the
distribution of the underlying pathology which is thought to be so-called Charcot-Bouchard aneurysms or microaneurysms. these are small aneurysms typically
between 0.3 and 0.9mm in size arising from small perforating vessels whose diameter is 0.1 to 0.3mm. They are somewhat controversial and are not usually identified on imaging. the distribution of Charcot-Bouchard aneurysms matches that of hypertensive hemorrhages, with most being found in the lenticulostriate vessels of the basal ganglia. these aneurysms arise as a result of chronic changes within the walls of these perforating vessels. These vessels can go on to thrombose in which
case you develop a lacunar infarct, they can leak resulting in microhaemorrhage, or they can rupture resulting in true
hemorrhage. the distribution of microhemorrhages
acting as a surrogate for Charcot-Bouchard aneurysms is seen on MRI with
T2* weighted imaging or susceptibility weighted imaging, as small regions of signal drop typically seen in and around the basal ganglia in chronic uncontrolled hypertension. these should be distinguished from the
microhemorrhages seen in cerebral amyloid angiopathy which underlie most cases of primary lobar haemorrhage where they are located peripherally with the
brain. as a differential on MRI appearances is
that of multiple cavernous malformations seen either as an autosomal dominant inherited condition or as the result of prior cranial irradiation. the location of hypertensive
hemorrhages deep within the brain and usually adjacent to the ventricles
makes them prone to extend into the ventricular system. on the first image we can see a left
sided basal ganglia hemorrhage extending into the left
lateral ventricle. on the second image a pontine hemorrhage extends posteriorly into the fourth ventricle and extends superiorly through the aqueduct of Sylvius and into the third ventricle. when such extension occurs it’s not
surprising that obstructed non- communicating hydrocephalus develops as is seen in this case, with marked prominence of the temporal horns and some early transependymal oedema. The overlying sulci are also effaced. The differential for a hypotensive
hemorrhage includes an underline tumour, an underlying vascular malformation, either a small AVM or a cavernous malformation and specifically in the case
of basal ganglia haemorrhages that of underlying moya moya disease where the abnormal enlarged perforator vessels are prone
to hemorrhage. this is typically the case in adults
rather than children who tend to present instead with ischemic symptoms, and finally with venus infarcts which typically also hemorrhage in this location. Deep vein thrombosis of the internal cerebral vein, or vein of Galen, or the basal veins of Rosenthal should be suspected. You can read more about basal ganglia
and hypertensive hemorrhages on Radiopaedia.org In our next video we will be covering lobar haemorrhages. See you then.

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  1. Omg guys i love your videos , But i can hardly understand what you say. English is not my native language and i usually i understand it perfectly, but in Your videos i cant 🙁

  2. Thanks so much for this series Dr Gaillard! Being a medical student (in your home state in fact!) I find we don't get enough radiology teaching, and this was an amazing learning resource. Looking forward to learning some emergency radiology via the new online course!

  3. awesome videos on CNS hemorrages, comparing and contrasting the difference, by location and by pathology, and presentation

    your way of explaining REALLY helps solidify and put together loose-ends left by reading chapters on chapters of books

  4. This is an outstanding lecture series, impeccably presented and a perfect refresher for the non-neuroradiologist. The lectures are pithy, and packed with important detail. I salute you sir!

  5. Simply excellent. Very grateful for clear, concise and well presented video. Thank you for the great channel. 😁 7/8/2019

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