A 58-year-old man with a 15-year history of hypertension (BP usually 160–180/100–110 mmHg, poorly controlled) presents to the emergency department with sudden-onset severe occipital headache, neck stiffness, and vomiting. On examination, he is alert but confused, with a blood pressure of 210/130 mmHg. Fundoscopy reveals papilledema. Non-contrast CT brain shows a hyperdense lesion in the basal ganglia with intraventricular extension and mild hydrocephalus. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Hypertensive Intracerebral Hemorrhage ### Key Features of the Case **Key Point:** The combination of chronic uncontrolled hypertension, sudden severe headache, acute confusion, neck stiffness, and a hyperdense basal ganglia lesion on CT is pathognomonic for hypertensive intracerebral hemorrhage (ICH). ### Pathophysiology 1. Chronic hypertension causes lipohyalinosis of small penetrating arteries (especially lenticulostriate branches of the middle cerebral artery). 2. These weakened vessels rupture, causing acute parenchymal bleeding. 3. The basal ganglia is the most common site (putaminal and caudate hemorrhages account for ~35–50% of hypertensive ICH). 4. Intraventricular extension occurs when blood tracks into the ventricular system, causing hydrocephalus and increased intracranial pressure. ### Clinical Presentation | Feature | Hypertensive ICH | SAH | Ischemic Stroke | |---------|------------------|-----|------------------| | **Onset** | Sudden | Sudden, "thunderclap" | Sudden or gradual | | **Headache** | Severe, progressive | Severe, maximal at onset | Absent or mild | | **Neck stiffness** | Present (IVH extension) | Prominent (meningeal irritation) | Absent | | **Focal deficits** | Present (hemiparesis, aphasia) | May be absent initially | Present | | **CT appearance** | Hyperdense parenchymal lesion | Blood in subarachnoid space, basal cisterns | Hypodense (early ischemia subtle) | | **BP at presentation** | Very elevated (160–220 mmHg) | Variable | Often normal or mildly elevated | **High-Yield:** Basal ganglia hemorrhage typically presents with contralateral hemiparesis, hemisensory loss, and homonymous hemianopia (due to internal capsule involvement). ### Imaging Findings - **Non-contrast CT:** Hyperdense (Hounsfield units 60–80) lesion within brain parenchyma. - **Location clues:** Basal ganglia (most common in hypertensive ICH), thalamus, pons, cerebellum. - **Intraventricular extension:** Indicates larger volume and worse prognosis; may cause acute obstructive hydrocephalus requiring urgent ventricular drainage. ### Management Priorities 1. **Blood pressure control:** Target SBP 130–150 mmHg (aggressive lowering in first 24 hours reduces hematoma expansion). 2. **Reversal of anticoagulation** (if applicable). 3. **Seizure prophylaxis** (lorazepam, phenytoin). 4. **Airway protection and ICU monitoring.** 5. **Neurosurgical consultation** for large hematomas (>30 mL) or intraventricular hemorrhage with hydrocephalus. **Clinical Pearl:** Papilledema at presentation suggests chronically elevated intracranial pressure from chronic hypertension, not acute ICH alone—this reinforces the diagnosis of longstanding uncontrolled hypertension. ### Why This Is Not the Other Diagnoses - **Subarachnoid hemorrhage:** Typically presents with blood in subarachnoid spaces on CT (not parenchymal), and the patient would have a history of aneurysm risk or sudden "worst headache of life." Basal ganglia location is atypical for aneurysmal SAH. - **Hemorrhagic transformation of ischemic stroke:** Would show a hypodense ischemic core with peripheral hemorrhage; no prior ischemic event history given. - **Subdural hematoma:** Would show a crescent-shaped collection over the convexity, not a basal ganglia lesion; no head trauma history provided.