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Intracerebral hemorrhage

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Intracerebral hemorrhage

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USMLE® Step 1 style questions USMLE

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An 82-year-old woman is brought to the emergency department for evaluation of sudden onset left-sided weakness and lethargy. The patient lives at home with her son, who found the patient lethargic and unable to move the left side of her body. The son states over the past year, the patient has been forgetting names of common people as well as losing her abilities to perform activities of daily living.  She recently became lost in the parking lot of a grocery store she has been shopping at for decades. She has no past medical history. Her temperature is 37°C (98.6°F), pulse is 101/min and regular, and blood pressure is 171/94 mmHg. The patient appears somnolent but is arousable to voice and pain. Physical examination reveals marked weakness of the left upper and left lower extremity with associated decreased sensation in the left arm and leg. The patient’s eyes are currently deviated towards the right. A noncontrast CT of the head is shown below:


Reproduced from: Radiopaedia  

Which of the following best describes the most likely etiology of this patient’s clinical presentation?   

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Content Reviewers

Rishi Desai, MD, MPH,Yifan Xiao, MD

There are two main types of stroke: a hemorrhagic stroke, which occurs when an artery ruptures and bleeds within the brain, and an ischemic stroke, which occurs when an artery gets blocked.

Hemorrhagic strokes can be further split into two types, an intracerebral hemorrhage which is when bleeding occurs within the cerebrum, and a subarachnoid hemorrhage which is when bleeding occurs between the pia mater and arachnoid mater of the meninges - the inner and middle layers that wrap around the brain.

We’ll be focusing on intracerebral hemorrhages which are more common.

An intracerebral hemorrhage that involves just the brain tissue is called an intraparenchymal hemorrhage, whereas if the blood extends into the ventricles of the brain which store cerebrospinal fluid, it’s called an intraventricular hemorrhage.

OK - let’s start with some basic brain anatomy. The brain has a few regions - the most obvious is the cerebrum, which is divided into two cerebral hemispheres, each of which has a cortex - an outer region - divided into four lobes including the frontal lobe, parietal lobe, temporal lobe, and the occipital lobe.

There are also a number of additional structures - including the cerebellum, which is down below, as well as the brainstem which connects to the spinal cord.

The right cerebrum controls muscles on the left side of your body and vice versa.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Hemorrhagic transformation after cerebral infarction: current concepts and challenges" Annuals of Translational Medicine (2014)
  6. "Intracerebral and subarachnoid hemorrhage in patients with cancer" Neurology (2010)
  7. "Intracranial Hemorrhage" Emergency Medicine Clinics of North America (2012)