Hemorrhagic Stroke

      The four major causes of hemorrhagic stroke are hypertension, hemorrhagic infarction, hypocoagulable state, and amyloid angiopathy. The criteria for hypertensive hemorrhage include a hypertensive patient, 60 years of age or older, and a basal ganglia or thalamic location of the hemorrhage. A CT scan is the procedure of choice for evaluating these patients. Arteriography is necessary only if one of these criteria is missing. Hypertensive hemorrhages are often large and devastating. Since they are deep hemorrhages and near ventricular surfaces, ventricular rupture is common. One-half of hypertensive hemorrhages occur in the putamen; the thalamus in 25%; pons and brainstem, 10%; cerebellum, 10%, and cerebral hemispheres, 5%.

      In stroke patients, despite the fact that the CT is often negative for the first 24-48 hours, it is often obtained on the day of admission to exclude an intracerebral hemorrhage before the patient is placed on anticoagulant therapy. Hemorrhage into an infarct can occur during the first week, usually between the third and fifth days. Hemorrhagic infarction is a hallmark of embolic infarction. This occurs after the embolus breaks up, resulting in reperfusion of the infarcted area. As mentioned above, hemorrhage is also common with venous infarction. Endnote

      Amyloid angiopathy occurs in the elderly, generally over 70 years of age, and is associated with Alzheimer's disease. It results from deposition of eosinophilic material in the media and adventitia of small arteries and arterioles of the cortex and leptomeninges. Fibrinoid degeneration and microaneurysmal dilatation lead to vessel rupture and hemorrhage. The typical imaging pattern is multiple, usually relatively small, cortical hemorrhages that spare the white matter and cerebellum. 

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