Hypertensive Hemorrhage

A 54-year-old female is brought to the ER by her husband because of right sided weakness and lethargy preceeded by severe headache.The patient has a long history of hypertension but stopped taking her medications about 3 months previously. The husband relates that this is due to depression, which was diagnosed 6 months previously. The patient also has a 20 pack-year history of smoking, and is 8 years status-post 2-vessel coronary bypass. Physical exam reveals a blood pressure of 236/114, normal body temperature, normal respirations and has a pulse of 86. Neurologically the patient is lethargic, has a right facial palsy, a right Babinsky, absent motor strength in the right upper and lower extremities and positive doll’s eye.

The following laboratory data reveal:

Hgb — 17 gms, Hct — 51%,

WBC — 13,500 with 76% neutrophils, 20% lymphocytes and 4% monocytes, platelets 350,000

Glucose — 95% mg/dl

EKG — normal sinus rhythm with changes of left ventricular hypertrophy

You order a CT-scan which reveals reveals hemorrhage of left basal ganglia

Questions:

1. The most likely diagnosis in this patient is:

A. Intracerebral hemorrhage secondary to a vascular malformation

B. Intracerebral hemorrhage secondary to cerebral amyloid angiopathy

C. Intracerebral hemorrhage secondary to hypertension

D. Intracerebral hemorrhage secondary to ruptured berry aneurysm

E. Intracerebral hemorrhage secondary to hemorrhagic infarct

Correct Answer C

2. The most common cause of spontaneous basal ganglia hemorrhage is:

A. Vascular malformations

B. Hypertension

C. Cerebral amyloid angiopathy

D. Vasculitis with thrombosis

E. Hypercoagulable state (polycythemia)

Correct Answer B

Shortly after admission, the patient had a cardiorespiratory arrest requiring intubation. She does not respond to attempts at resuscitation and dies. An autopsy is performed. The brain shows a left deep intracerebral hematoma with extension to the lateral ventricles.

Questions:

3. The cause of death of this patient is:

A. Hypertensive hemorrhage of left basal ganglion extending into the lateral ventricles

B. Ruptured berry aneurysm with subarachnoid hemorrhage extending into the lateral ventricles

C. Ruptured arterio-venous malformation

D. Intracerebral and intraventricular hemorrhage secondary to an hemorrhagic infarct.

E. Bleeding into metastatic melanoma of cerebrum

Correct Answer: A

4. Charcot-Bouchard aneurysms are:

A. Saccular aneurysms arising in the Circle of Willis

B. Arteriovenous malformation

C. Aneurysms associated with cerebral amyloid angiopathy

D. Minute aneurysms associated with hypertension

E. Infectious aneurysms

Correct Answer: D

5. Slit hemorrhages are:

A. Small intracerebral hypertensive hemorrhages secondary to rupture of deep penetrating arterioles involved by arteriolar sclerosis

B. Lacunar type hemorrhages secondary to hypercoagulable states

C. Hypertensive hemorrhage resulting in clinical dementia

D. Intracerebral hemorrhage secondary to a venous angiomas

E. Small hypertensive hemorrhage which when resorbed leaves a slit-like cavity.

Correct Answer: E

6. The etiology of this patients elevated hemoglobin and hematocrit is most likely:

A. Polycythemia vera

B. Inappropriate erythropoietin production

C. Past and current history of smoking

D. Familial polycythemia

E. Undetected hemoglobinopathy

Correct Answer: C