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First, let's take a look at hypertensive hemorrhages.
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This is a classic example of a hypertensive hemorrhage.
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There's a deep area of hyperdense blood in the subcortical
regions and we see these
in the thalamus, internal capsule of pons, and even in the
cerebellum. Hypertensive
hemorrhages are subcortical. They occur in small vessel
territories like the basal ganglia,
internal capsule thalamus and cerebellum. They present with
focal neurologic deficits in a
patient who presents with new hypertension or refractory
hypertension from longstanding
disease. We manage this typically with monitoring over time
to ensure there's not
propagation and if so some patients rarely may need surgery
but the vast majority are
managed conservatively. And the long-term treatment that is
necessary is management
of the patient's hypertension. Now let's talk about the
second category or hemorrhagic
transformation of an ischemic infarct. This is the second
cause of an intraparenchymal
hemorrhage. Here, we're looking at a number of the images of
a patient who presented
with a new focal deficit. This patient had a right
hemiplegia and we were concerned
about a left hemispheric problem. On the far right, you're
looking at perfusion image
and that green is an area of reduced perfusion. That's an
area at risk for stroke. There is
reduced perfusion in the left MCA territory. The patient had
a non-contrast head CT
which you see in the middle which shows some early blurring
of the gray white junction
in the subcortical structures of the insular cortex of the
left MCA territory and then
on the CTA at the far right we see a cutoff sign. You can
see a really healthy nice
looking right MCA with full opacification and blood and then
a cutoff at the left MCA
from an acute thrombus in that territory. So this is the
typical imaging findings of a patient
presenting with a left MCA syndrome. This patient underwent
intervention and a day after
intervention instead of seeing an area of restricted
diffusion on the diffusion weighted
image, we saw this kind of black and white heterogenous
area. That was followed by a
head CT around that same time for neurologic deterioration
and what we're seeing
was hyperdensity in that area of recent stroke consistent
with new bleeding or hemorrhagic
transformation of this patient's ischemic infarct. And then
ultimately on the susceptibility
weighted image which is an MRI sequence, we see this area of
dark signal, reduced
signal on the susceptibility weighted image which is
consistent with a hemorrhagic
infarct. Typically, we see hemorrhagic transformation within
that three to five days or
sometimes out to seven days after an ischemic infarct.
Hemorrhagic transformation
is more common in large strokes. This patient presented with
a large paroxysmal MCA
occlusion, a large area of tissue that ultimately was
involved. And those patients are
at higher risk of hemorrhage, particularly after acute
intervention or other reperfusion
interventions.