A 58-year-old hypertensive man from Delhi presents to the emergency department with sudden-onset severe headache, neck stiffness, and vomiting. On examination, he is drowsy with a blood pressure of 180/110 mmHg. Non-contrast CT head shows a hyperdense lesion in the basal ganglia with intraventricular extension. What is the most likely location of the primary hemorrhage?

Explanation

## Clinical Presentation & Imaging Findings The patient presents with classic signs of acute intracerebral hemorrhage (ICH): sudden severe headache, neck stiffness, vomiting, and altered consciousness. The non-contrast CT finding of a hyperdense lesion in the basal ganglia with intraventricular extension is pathognomonic. ## Hypertensive Hemorrhage Distribution **Key Point:** Chronic hypertension causes lipohyalinosis of small penetrating arteries, leading to ICH in characteristic locations. | Location | Artery | Frequency | Clinical Features | |----------|--------|-----------|-------------------| | **Putamen/Globus pallidus (lateral lenticulostriate)** | Lateral lenticulostriate (MCA perforators) | 35–50% | Contralateral hemiparesis, hemisensory loss, homonymous hemianopia | | Thalamus | Perforating branches of PCA | 15–25% | Vertical gaze palsy, altered consciousness, sensory loss | | Pons | Perforating branches of basilar artery | 5–10% | Pinpoint pupils, locked-in syndrome, respiratory depression | | Cerebellum | SCA, AICA, PICA | 5–10% | Ataxia, headache, hydrocephalus from mass effect | | Lobar (subcortical white matter) | Cortical branches | 10–20% | Often associated with amyloid angiopathy in elderly | ## Why Putamen is Most Likely **High-Yield:** Putaminal hemorrhage is the most common site of hypertensive ICH, accounting for ~40% of cases. The lateral lenticulostriate arteries (branches of the middle cerebral artery) are the primary vessels affected by lipohyalinosis in chronic hypertension. **Clinical Pearl:** Putaminal hemorrhage with intraventricular extension (as seen on this patient's CT) is classic for hypertensive ICH and carries a worse prognosis due to increased intracranial pressure and risk of herniation. ## Imaging Characteristics on Non-Contrast CT 1. **Acute phase (0–7 days):** Hyperdense (white) due to high protein content of fresh blood 2. **Basal ganglia location:** Putamen is lateral to the internal capsule; thalamic bleeds are medial 3. **Intraventricular extension:** Indicates rupture into lateral ventricle, worsening prognosis **Mnemonic: "PPTC"** — Putamen, Pons, Thalamus, Cerebellum are the four classic sites of hypertensive ICH (in order of frequency). [cite:Harrison 21e Ch 451]