A 65-year-old man is brought to the emergency department 30 minutes after the acute onset of headache, nausea, and sudden loss of balance. The patient is unable to stand or walk, but there is no loss of muscular strength or sensory deficits. Consciousness is preserved, and the patient is oriented to person, space, and time. He says that he had hypertension for a long time but has not taken any antihypertensive therapy. His blood pressure is now 166/98 mm Hg, and his pulse is 65/min. A CT scan of the head reveals an acute intracranial hematoma. Which of the following is the most likely location of the hematoma? (A) Cerebellum (B) Cerebral white matter (C) Epidural space (D) Pons (E) Putamen (F) Thalamus
Cerebellum, because its function is posture and balance.
The correct answer is A. Among hypertensive intracerebral bleeds, cerebellar hematomas merit special consideration. A hematoma within a cerebellar hemisphere manifests with sudden onset of headache and ataxia in an otherwise lucid patient. This highly characteristic presentation warrants immediate medical attention because of the possibility of full recovery if properly treated. An intracerebral hematoma in the cerebral white matter (choice B) is usually accompanied by lateralized motor and/or sensory deficits. Epidural hemorrhage (choice C) is always of traumatic origin and manifests with the characteristic talk-and-die syndrome. There is a lucid interval between trauma and coma. Following hemorrhages in the pons (choice D), the patient falls into immediate coma with quadriparesis and usually dies of cardiorespiratory arrest. The putamen (choice E) is the most frequent site of hypertensive bleeding. Putamenal hemorrhage usually involves the adjacent internal capsule, leading to contralateral hemiparesis, hemianesthesia. and hemianopia. Bleeding into the thalamus (choice F) may be suspected when the patient manifests hemianesthesia that precedes hemiparesis.
