Case 9511 Hypertensive microangiopathy Schepers S, Barthels C Section: Neuroradiology Published: 2011, Nov. 3 Patient: 67 year(s), male Authors' Institution Department of Radiology, Jessa ziekenhuis campus Salvator Hasselt, Belgium Clinical History A 67-year-old man presented at the emergency room complaining of acute headache and vertigo. Clinical examination showed a positive Romberg's-test and an abnormal finger-nose test. He also had a paresis of his left leg and dysarthria. The systolic blood pressure was 200mm Hg. His brother died from a brain haemorrhage. Imaging Findings A CT examination of the brain was performed, showing periventricular leucoencephalopathy and a spontaneous hyperintense lesion on the right side of the pons, consistent with an acute haemorrhage. The next day, an angio-ct of the brain was performed, showing no vascular abnormalities. Brain-MRI showed the haemorrhage in the pons and periventricular white matter hyperintensities. In addition, there were multiple punctiform blooming artefacts subcortical in both hemispheres and in the basal ganglia on the susceptibility-weighted images (SWI). Discussion
Multifocal small hypointense lesions on T2*-weighted gradient-echo images have been reported to be commonly observed in the brain of patients with systemic hypertension, spontaneous brain haemorrhage and ischemic lesions. Systemic hypertension is the leading condition associated with brain haemorrhage. Histopathological analysis proved that the hypointense lesions are a result of haemosiderin deposits, indicative of old microhaemorrhage. Tsushima et al. found microhaemorrhages on the T2*-weighted gradient-echo images of 9, 8% of the patients who underwent MR imaging examinations. Patients with microhaemorrhages were significantly older and had a higher frequency of hypertension. These microhaemorrhages, resulting from hypertensive microangiopathy, were most frequently located in the lentiform nucleus, thalamus, and cortical-subcortical regions [1]. On the other hand, cerebral amyloid angiopathy (CAA) is another important but underrecognised cause of cerebrovascular disorders. It predominantly affects elderly patients and results from deposition of beta-amyloid protein in cortical, subcortical and leptomeningeal vessels. CAA-related haemorrhages characteristically involve the cortex and subcortical white matter. Deep central gray nuclei, corpus callosum and cerebellum are primarily involved on rare occasions, and CAA is almost never observed to be a cause of primary brain stem haematomas [2]. On the contrary, the most common locations of hypertensive haemorrhage are the basal ganglia, thalamus, cerebellum or pons. Therefore, in our case, the macrohaemorrhage was most probably the result of a hypertensive microangiopathy rather than of CAA. Final Diagnosis Hypertensive microangiopathy Differential Diagnosis List Hypertensive microangiopathy, Cerebral amyloid angiopathy, Cavernous angiomas Figures Figure 1 Axial CT images without contrast
Macrohaemorrhage on the right side of the pons. Imaging Technique: CT; Figure 2 Axial T1-weighted SE images Pontine macrohaemorrhage
Figure 3 Sagittal T1-weighted SE images Pontine macrohaemorrhage Figure 4 Axial SWI images
Blooming artefacts (microhaemorrhages) in corticosubcortical regions and deep gray matter. Figure 5 Axial T2-weighted TSE images At the same level as figure 4: no microhaemorrhages visible on a standard T2 TSE image.
Figure 6 Axial FLAIR images Bilateral periventricular hyperintensities due to ischaemic disease. Figure 7 Additional images Axial FLAIR image: bilateral periventricular hyperintensities.
Axial FLAIR image. Axial FLAIR image.
Axial FLAIR image. Axial FLAIR image.
Axial FLAIR image: pontine macrohaemorrhage. Axial SWI image.
Axial SWI image: blooming artefacts (microhaemorrhages) in corticosubcortical regions. Axial SWI image: blooming artefacts in corticosubcortical regions and deep gray matter.
Axial SWI image. Axial SWI image. MeSH Intracranial Hemorrhage, Hypertensive [C10.228.140.300.535.325] Bleeding within the brain or adjacent structures which results from systemic HYPERTENSION,
usually in association with INTRACRANIAL ARTERIOSCLEROSIS. Hypertensive hemorrhages are most frequent in the BASAL GANGLIA; CEREBELLUM; PONS; and THALAMUS; but may also involve the CEREBRAL CORTEX, subcortical white matter, and other brain structures. References [1] Tsushima Y, Aoki J, Endo K (2003) Brain microhemorrhages detected on T2*-weighted gradient-echo MR images American journal of neuroradiology 24: 88-96 [2] Cho CP, Kotsenas AL, Broderick DF (2006) Cerebral amyloid angiopathy: CT and MR imaging findings Radiographics 26: 1517-1531 Citation Schepers S, Barthels C (2011, Nov. 3) Hypertensive microangiopathy {Online} URL: http://www.eurorad.org/case.php?id=9511