A 75 year-old woman with HTN, HLD, and ongoing tobacco use presents with an acute-onset severe headache while preparing her dinner. In the ED, her mental status declines, necessitating intubation for airway protection. A non-contrast head CT is obtained. What is the underlying etiology of her medial frontal intraparenchymal hematoma?
Yes! While aneurysmal rupture will cause bleeding into the subarachnoid space, there are certain locations in which aneurysms are known to cause intraparenchymal hematomas (I think of them so forcefully dissecting into and through the tissue itself): temporal lobe from MCA aneurysms and frontal lobe from ACA/ACoM aneurysms. You could also have a pericallosal aneurysm rupture that causes isolated IVH.
This is always a good consideration when you see a new hemorrhagic stroke. However, the degree of associated SAH and IVH would be unusual for hemorrhagic conversion of an ischemic stroke. The ACA territory on that side also doesn't appear to be infarcted.
The location of her IPH is not in one of the classic locations for hypertensive bleeds (i.e. basal ganglia, thalamus, pons, cerebellum), and there's also SAH. CAA could cause both a lobar IPH and SAH, but the IPH here is not a typical lobar bleed.
Hemorrhagic stroke associated with meningitis is very rare, and the clinical history given would not support this.
Trauma is the most common etiology for SAH. However, there was no trauma in the clinical history here, and this IPH location would be atypical for it.
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