## Location of Hypertensive ICH **Key Point:** Hypertensive intracerebral hemorrhage (ICH) occurs in characteristic locations due to rupture of lipohyalinotic small penetrating arteries damaged by chronic hypertension. ### Distribution of Hypertensive ICH | Location | Frequency | Artery Involved | Clinical Features | |----------|-----------|-----------------|-------------------| | **Putamen/External Capsule** | 35–50% | Lateral lenticulostriate arteries | Contralateral hemiparesis, hemisensory loss, homonymous hemianopia | | **Thalamus** | 15–25% | Thalamoperforating arteries | Vertical gaze palsy, sensory loss, altered consciousness | | **Pons** | 5–12% | Pontine perforating arteries | Pinpoint pupils, quadriplegia, coma | | **Cerebellum** | 5–10% | Superior cerebellar artery | Ataxia, headache, hydrocephalus risk | | **Lobar (subcortical)** | 10–20% | Cortical penetrating vessels | Variable; often associated with amyloid angiopathy in elderly | **High-Yield:** The "deep" hypertensive bleeds (putamen, thalamus, pons, cerebellum) account for ~85% of hypertensive ICH. Lobar hemorrhages in hypertensive patients should raise suspicion for **cerebral amyloid angiopathy (CAA)**, especially if the patient is elderly or has recurrent bleeds. ### Why Putamen/External Capsule? The lateral lenticulostriate arteries (branches of the middle cerebral artery) are small penetrating vessels that are particularly vulnerable to lipohyalinosis—a pathological hallmark of chronic hypertension. These vessels weaken and rupture, causing the most frequent type of hypertensive ICH. **Clinical Pearl:** A putaminal hemorrhage with intraventricular extension often causes rapid deterioration due to obstructive hydrocephalus and midline shift. [cite:Harrison 21e Ch 296]
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