## Most Common Site of Hypertensive ICH **Key Point:** Hypertensive intracerebral hemorrhage has a characteristic distribution pattern based on the location of lipohyalinosis in small penetrating arteries. ### Distribution Pattern of Hypertensive ICH | Location | Frequency | Artery Involved | Clinical Features | |----------|-----------|-----------------|-------------------| | **Putamen/External capsule** | **50–60%** | Lenticulostriate arteries | Contralateral hemiparesis, hemisensory loss, aphasia (if dominant) | | Thalamus | 15–25% | Thalamoperforating arteries | Vertical gaze palsy, sensory loss, altered consciousness | | Pons | 5–10% | Pontine perforating arteries | Pinpoint pupils, locked-in syndrome, respiratory failure | | Cerebellum | 5–10% | Superior cerebellar artery | Ataxia, headache, hydrocephalus risk | | Lobar (cortical) | 10–20% | Cortical branches (often amyloid) | Seizures, focal deficits; suggests amyloid angiopathy if recurrent | **High-Yield:** The **putamen and external capsule** account for more than half of all hypertensive hemorrhages because the lenticulostriate arteries (lateral and medial) are the most common sites of lipohyalinotic degeneration in chronic hypertension. ### Pathophysiology 1. Chronic hypertension → lipohyalinosis of small penetrating arteries 2. Microaneurysm formation (Charcot-Bouchard aneurysms) 3. Rupture → ICH, typically in distribution of penetrating vessels 4. Putaminal/capsular location is most vulnerable due to vessel caliber and pressure exposure **Clinical Pearl:** Lobar hemorrhages (cortical distribution) in a hypertensive patient should raise suspicion for **cerebral amyloid angiopathy (CAA)**, especially if recurrent or in an older patient without severe hypertension. **Mnemonic:** **PPTC** — Putamen (most common), Pons, Thalamus, Cerebellum — the classic hypertensive ICH sites in order of frequency. [cite:Harrison 21e Ch 435]
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