0:01

So in considering patients who have worst headache

0:04

of life or thunderclap headache, we're most

0:07

concerned about the possibility of an aneurysm

0:10

bleeding because that has very poor prognosis.

0:14

We're concerned about other vascular lesions,

0:16

such as arteriovenous malformations or fistulae.

0:20

But if you look at all comers for those patients

0:23

who have intracranial hemorrhage, the most common

0:25

source is probably going to be trauma, and the second

0:29

most common source will be hypertensive bleeding.

0:32

Now, hypertensive bleeding usually will

0:34

bleed into the parenchyma rather than

0:37

primarily into the subarachnoid space.

0:41

Let's look at this case.

0:42

So this patient was hypertensive, and what we see

0:45

is intraventricular hemorrhage with a large cast

0:48

of blood in the left lateral ventricle as well

0:52

as in the third ventricle, and it's collecting in

0:55

the occipital horn of the left lateral ventricle.

0:59

There are blood products also in the cerebral

1:02

aqueduct and extending into the fourth ventricle.

1:06

What are we missing here?

1:08

We're not actually seeing very much

1:09

in the way of subarachnoid hemorrhage.

1:12

An aneurysm is more likely to bleed into the

1:15

subarachnoid space because the blood

1:16

vessels are floating in the cerebrospinal fluid.

1:19

In this case, we have almost

1:21

exclusively intraventricular hemorrhage.

1:24

When that occurs, I suggest that you look

1:26

at the very thin section images for the

1:29

potential for a parenchymal hemorrhage,

1:32

causing bleeding into the ventricular system.

1:37

So, nothing really in the basal cisterns here,

1:41

nothing in the interpeduncular cistern, nothing in the

1:44

Sylvian fissure, but what you see is this focal area

1:49

right here of blood, which is outside the ventricle.

1:54

Here's the lateral ventricle.

1:56

But you see that this is asymmetric

1:57

with the contralateral side.

1:59

Can I convince you that this is not in the ventricle?

2:03

Here's the frontal horn, here's the foramen

2:06

of Monro, here's the occipital horn.

2:08

This is a bleed into the thalamus.

2:11

It's a bleed into the medial

2:12

thalamus from hypertension.

2:15

Hypertensive bleeds have a predilection

2:17

for bleeding into the deep gray matter.

2:19

That includes the basal ganglia,

2:21

the thalamus, as well as the dentate nucleus.

2:24

This patient did have hypertension, and that

2:28

is one of the common causes of intraparenchymal

2:31

hemorrhage in adults, as well as, obviously,

2:36

adults who have high blood pressure.

2:39

Unfortunately, this, the presence of the patient

2:44

having high blood pressure, and the classic

2:48

deep gray matter bleed into the ventricles in the

2:52

absence of subarachnoid hemorrhage, often cannot

2:56

convince the clinicians to give up doing a CTA.

3:01

So even though the patient's got a blood pressure

3:03

of 220 over 140, even though we say to them,

3:07

this is a hypertensive bleed in the thalamus

3:09

perforating into the ventricular system, sure enough,

3:12

they will often order the CTA, as is seen here.

3:17

And here, if we look on our coronal image,

3:19

we see no evidence of aneurysm of the

3:22

distal internal carotid artery, the ACOM,

3:25

of the middle cerebral artery distribution,

3:27

of the lenticulostriate branches,

3:30

of the basilar tip, of any of the basilar branches,

3:33

or the vertebrobasilar junction—all clean.

3:37

But, even though I can say and yell, and scream,

3:41

"Look, this is a hypertensive bleed! I can see

3:43

it! It's in the thalamus, right here, bleeding into

3:47

the ventricular system," invariably, they order a CTA.

3:51

So, don't be too shocked by that.