ICH Flashcards
What is the most common cause of hypertensive intracerebral hemorrhage (ICH)?
A) Rupture of a saccular aneurysm
B) Rupture of a small penetrating artery
C) Traumatic brain injury
D) Cerebral venous sinus thrombosis
Answer: B) Rupture of a small penetrating artery
Rationale: Hypertensive ICH occurs due to spontaneous rupture of small penetrating arteries, primarily in deep brain structures such as the basal ganglia, thalamus, cerebellum, and pons.
Which of the following is the most common site of hypertensive ICH?
A) Occipital lobe
B) Basal ganglia (putamen)
C) Hippocampus
D) Corpus callosum
Answer: B) Basal ganglia (putamen)
Rationale: The putamen (part of the basal ganglia) is the most common site of hypertensive ICH due to the vulnerability of small penetrating arteries to chronic hypertension.
Which clinical sign is most suggestive of a putaminal hemorrhage?
A) Ipsilateral ataxia
B) Contralateral hemiparesis
C) Cortical blindness
D) Bilateral lower limb weakness
Answer: B) Contralateral hemiparesis
Rationale: A putaminal hemorrhage often damages the adjacent internal capsule, leading to contralateral hemiparesis, facial sagging, slurred speech, and eye deviation away from the hemiparesis.
A patient with hypertensive ICH deteriorates to a comatose state with deep, irregular respiration, a dilated ipsilateral pupil, and decerebrate rigidity. What is the most likely explanation?
A) Status epilepticus
B) Early hydrocephalus
C) Upper brainstem compression
D) Cortical infarction
Answer: C) Upper brainstem compression
Rationale: Large hemorrhages can compress the upper brainstem, leading to coma, respiratory irregularities, a fixed ipsilateral pupil, and decerebrate posturing—indicating herniation.
Which imaging modality is the most appropriate for diagnosing hypertensive ICH?
A) MRI with contrast
B) Non-contrast CT scan
C) Digital subtraction angiography
D) PET scan
Answer: B) Non-contrast CT scan
Rationale: A non-contrast CT scan is the gold standard for diagnosing acute ICH, as it quickly identifies hyperdense hemorrhagic lesions.
Which of the following conditions should be considered when ICH occurs in a non-hypertensive patient?
A) Cerebral amyloid angiopathy (CAA)
B) Parkinson’s disease
C) Myasthenia gravis
D) Bell’s palsy
Answer: A) Cerebral amyloid angiopathy (CAA)
Rationale: Non-hypertensive causes of ICH include CAA, vascular malformations, neoplasms, vasculitis, and hemorrhagic disorders. CAA is particularly associated with lobar hemorrhages in elderly patients.
What pathological process occurs 1–6 months after a hypertensive ICH?
A) Complete hemorrhage resolution with no residual damage
B) Formation of a slitlike cavity with glial scarring
C) Continuous hematoma expansion
D) Transformation into a cystic neoplasm
Answer: B) Formation of a slitlike cavity with glial scarring
Rationale: Over 1–6 months, the hemorrhage is phagocytized by macrophages, leaving behind a slitlike cavity lined with a glial scar and hemosiderin-laden macrophages.
Which of the following symptoms is least common in hypertensive ICH?
A) Seizures
B) Headache
C) Vomiting
D) Progressive focal neurological deficit
Answer: A) Seizures
Rationale: Unlike lobar hemorrhages (which are more prone to seizures), hypertensive deep brain hemorrhages (e.g., basal ganglia, thalamus, pons) rarely present with seizures.
Which neurological deficit is most characteristic of a thalamic hemorrhage?
A) Ipsilateral hemiparesis
B) Contralateral hemiplegia with prominent sensory loss
C) Bilateral weakness
D) Pure motor deficit without sensory involvement
Answer: B) Contralateral hemiplegia with prominent sensory loss
Rationale: Thalamic hemorrhages often involve the internal capsule, leading to contralateral hemiplegia or hemiparesis with a prominent sensory deficit affecting all modalities.
A patient with a dominant thalamic hemorrhage is most likely to exhibit which of the following?
A) Fluent aphasia with impaired repetition
B) Non-fluent aphasia with preserved repetition
C) Global aphasia
D) Anomic aphasia
Answer: B) Non-fluent aphasia with preserved repetition
Rationale: In dominant thalamic hemorrhage, patients may have aphasia, often with preserved verbal repetition—a distinguishing feature compared to cortical aphasias.
Which ocular disturbance is most commonly associated with thalamic hemorrhage?
A) Upward gaze palsy
B) Horizontal gaze nystagmus
C) Downward and inward eye deviation (toward the nose)
D) Bilateral ptosis
Answer: C) Downward and inward eye deviation (toward the nose)
Rationale: Thalamic hemorrhages extending into the upper midbrain cause ocular disturbances, including downward and inward eye deviation, skew deviation, and paralysis of vertical gaze.
Which syndrome is associated with chronic contralateral pain following thalamic hemorrhage?
A) Brown-Séquard syndrome
B) Déjérine-Roussy syndrome
C) Wallenberg syndrome
D) Horner’s syndrome
Answer: B) Déjérine-Roussy syndrome
Rationale: Déjérine-Roussy syndrome (thalamic pain syndrome) may develop later in patients after a thalamic hemorrhage, causing chronic contralateral pain.
What is the most common clinical presentation of a pontine hemorrhage?
A) Gradual onset hemiparesis
B) Deep coma with quadriplegia
C) Vertigo and tinnitus
D) Hemianopia
Answer: B) Deep coma with quadriplegia
Rationale: Pontine hemorrhages are rapidly catastrophic, leading to deep coma, quadriplegia, pinpoint pupils, and often death or a locked-in state.
Which of the following ocular signs is most typical in pontine hemorrhage?
A) Bilateral mydriasis
B) Pinpoint reactive pupils
C) Upward gaze palsy
D) Bilateral ptosis
Answer: B) Pinpoint reactive pupils
Rationale: Pinpoint pupils (1 mm in size) that remain reactive to light are a hallmark of pontine hemorrhages, due to disruption of descending sympathetic pathways.
Which neurologic deficit is most indicative of an occipital lobe hemorrhage?
A) Dysphagia
B) Hemianopsia
C) Hemiparesis
D) Ataxia
Answer: B) Hemianopsia
Rationale: An occipital lobe hemorrhage typically presents with hemianopsia due to damage to the visual pathways.
What is the most common cause of lobar hemorrhage in the elderly?
A) Hypertension
B) Cerebral amyloid angiopathy (CAA)
C) Arteriovenous malformation (AVM)
D) Trauma
Answer: B) Cerebral amyloid angiopathy (CAA)
Rationale: CAA is a common cause of lobar hemorrhage in the elderly, leading to single or recurrent hemorrhages due to amyloid deposition in cerebral vessels.
Which apolipoprotein E (ApoE) alleles are associated with an increased risk of recurrent lobar hemorrhage in CAA?
A) ε1 and ε3
B) ε2 and ε4
C) ε3 and ε4
D) ε1 and ε2
Answer: B) ε2 and ε4
Rationale: The ε2 and ε4 alleles of ApoE increase the risk of recurrent lobar hemorrhage in CAA, possibly due to their effects on vascular amyloid deposition.
What is the recommended treatment for noninflammatory cerebral amyloid angiopathy (CAA)?
A) High-dose corticosteroids
B) Anticoagulation therapy
C) No specific treatment
D) Immunomodulatory therapy
Answer: C) No specific treatment
Rationale: Noninflammatory CAA has no specific treatment, but oral anticoagulants are avoided due to the high risk of hemorrhage.
What is the most likely mechanism of intracranial hemorrhage in cocaine and methamphetamine use?
A) Direct vessel wall toxicity
B) Acute severe hypertension
C) Hypercoagulability
D) Autoimmune vasculitis
Answer: B) Acute severe hypertension
Rationale: Cocaine and methamphetamine use increases sympathetic activity, leading to severe hypertension, which can cause ICH, ischemic stroke, or subarachnoid hemorrhage (SAH).
In head trauma, which brain regions are most commonly affected by intraparenchymal hemorrhage?
A) Occipital and parietal lobes
B) Temporal and inferior frontal lobes
C) Thalamus and brainstem
D) Cerebellum and occipital lobe
Answer: B) Temporal and inferior frontal lobes
Rationale: Head injury often causes intraparenchymal hemorrhages in the temporal and inferior frontal lobes due to impact against the skull.
Which type of hematologic disorder is most commonly associated with multiple intracranial hemorrhages?
A) Sickle cell disease
B) Leukemia and thrombocytopenia
C) Hemophilia A
D) Polycythemia vera
Answer: B) Leukemia and thrombocytopenia
Rationale: Leukemia, aplastic anemia, and thrombocytopenic purpura can lead to multiple ICHs, often accompanied by skin and mucosal bleeding.
Which tumor type is most commonly associated with intracranial hemorrhage?
A) Meningioma
B) Glioblastoma multiforme
C) Pituitary adenoma
D) Schwannoma
Answer: B) Glioblastoma multiforme
Rationale: Glioblastoma multiforme, choriocarcinoma, malignant melanoma, renal cell carcinoma, and bronchogenic carcinoma are frequently associated with hemorrhagic metastases.
What imaging finding is characteristic of hypertensive encephalopathy?
A) Temporal lobe hemorrhage
B) Reversible posterior leukoencephalopathy
C) Subdural hematoma
D) Midbrain infarction
Answer: B) Reversible posterior leukoencephalopathy
Rationale: Hypertensive encephalopathy presents with reversible posterior leukoencephalopathy syndrome (PRES), which predominantly affects the occipital and frontal lobes.
In cases of venous sinus thrombosis causing intracranial hemorrhage, what is the preferred treatment?
A) Antiplatelet therapy
B) IV anticoagulation
C) Emergency decompressive surgery
D) High-dose steroids
Answer: B) IV anticoagulation
Rationale: Despite the presence of hemorrhage, IV anticoagulation is used to reduce venous hypertension, limit venous infarction, and prevent further ICH progression.
