An older adult patient presents to the emergency department with a sudden onset of left-sided weakness and difficulty speaking. He has a history of hypertension that is not well-documented and does not regularly take any medications. A CT scan of his brain reveals a hemorrhagic stroke localized in the basal ganglia. There is no history of head trauma or recent anticoagulant use. What is the most likely cause of this stroke?
Group of answer choices
- Long-standing hypertension
- Cerebral amyloid angiopathy
- Hemorrhagic transformation of an ischemic stroke
- Rupture of a cerebral aneurysm
The correct answer is: Long-standing hypertension
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Explanation:
The patient’s presentation—sudden-onset focal neurologic deficits (left-sided weakness, speech difficulty) with a hemorrhagic stroke in the basal ganglia—is classic for hypertensive intracerebral hemorrhage (ICH).
Key Supporting Evidence:
- Location: The basal ganglia (especially the putamen) is the most common site of hypertensive hemorrhage.
- Risk Factors:
- Poorly controlled hypertension (major risk factor).
- No history of trauma/anticoagulants (rules out traumatic hemorrhage or coagulopathy-related bleeding).
- Absence of Alternative Causes:
- Cerebral amyloid angiopathy (CAA): Typically causes lobar hemorrhages (cortical/subcortical) in older adults, not deep structures like basal ganglia.
- Hemorrhagic transformation of ischemic stroke: Usually occurs days after ischemia, not as an initial presentation.
- Cerebral aneurysm rupture: Leads to subarachnoid hemorrhage (SAH), not intraparenchymal hemorrhage in the basal ganglia.
Pathophysiology:
Chronic hypertension causes lipohyalinosis (degeneration of small penetrating arteries) and microaneurysms (Charcot-Bouchard aneurysms), which rupture, leading to deep brain bleeds.
Thus, long-standing hypertension is the most likely cause.
