Intracerebral hemorrhage is characterized clinically by an abrupt onset and rapid evolution. Intracerebral hemorrhages are more common in males and show a higher incidence in blacks than in whites, probably due to the greater incidence of hypertension. Blacks dying of intracerebral hemorrhages are generally younger than their white counterparts.
Intracerebral hemorrhages are uncommon in the younger age groups. The hemorrhage usually occurs in individuals who are up and active rather than asleep. Hypertension is virtually always present. There is usually only one episode of hemorrhage at the time of the attack. Recurrence of bleeding is not usually encountered. The patient usually develops symptoms over a period of 2 h to hours. The primary sites for intracerebral hemorrhages are the putamen and adjacent internal capsule, the thalamus, the cerebellar hemispheres, the pons, and the white matter (Figure 3.10).
In hemorrhage in the putamen, the speech becomes slurred and the muscles of the face, arms, and legs gradually weaken. In thalamic hemorrhage, hemiparesis occurs secondary to pressure on the adjacent internal capsule. The sensory deficit is greater than the motor weakness. Cerebellar hemorrhage usually takes a period of several hours to develop. Loss of consciousness is uncommon. Repeated vomiting, occipital headache, vertigo, and inability to walk or stand are symptoms. Occasionally, the individual is thought to be intoxicated. In pontine hemorrhage, consciousness is lost almost immediately.
As in the case of ruptured berry aneurysms, most of the literature about intracerebral hemorrhage is clinically oriented and concerns hospital cases. The paper by Freytag is probably most relevant to a medical examiner's office, because 80% of the cases were autopsies carried out in a medical examiner's
office.51 Of the 393 cases studied, 40% of the hypertensive intracerebral hemorrhages originated in the striate body area, 16% in the pons, 15% in the thalamus, 12% in the cerebellum, and 10% in the cerebral white matter. Neither the cerebral nor cerebellar hemorrhages showed predilection for any side. Three percent of the cases showed multiple areas of origin for the hematomas, with five being the greatest number of multiple sites. There was no direct correlation between the severity of atherosclerosis of the basilar vessels and the development of intracerebral hemorrhage.
The age of the individuals ranged from 30 to 88 years of age, with an average of 55.5 years. Freytag pointed out that more than 50% of the hematomas occur between 40 and 60 years of age. Eleven percent of the patients, however, were in their thirties. Survival time was relatively short. Thus, 35% of the individuals were found dead or were dead on arrival at a hospital, 75% were either dead on arrival at a hospital or died within the first 24 h. Only 10% lived longer than 3 days. When hemorrhage occurred in the pons, 95% of the patients died within 24 h. Seventy-five percent of the hematomas
ruptured through the ventricular walls into the ventricles. Hemorrhages at sites close to the ventricles penetrated into the ventricles more often than those in remote areas. Thus, 97% of the thalamic hemorrhages ruptured into the ventricles, compared with only 40% of the cerebral white matter hematomas. In 6% of the cases, the intracerebral hematomas penetrated through the cortex and subarachnoid membrane into the subdural space. This was most common with the cerebellar hemorrhages. Only 15% of the intracere-bral hemorrhages penetrated through the cortex, producing subarachnoid hemorrhage. More than half (54%) of the patients developed secondary brain stem hemorrhages and edema.
In intracerebral hemorrhage, the brain is asymmetrically swollen, with the swollen hemisphere containing the hemorrhage. Subarachnoid hemorrhage may or may not be present on the base of the brain. On sectioning, the brain tissue adjacent to the hemorrhage is swollen and edematous. No brain tissue is present in the hematoma. Microscopic sections of adjacent brain tissue usually show severely sclerotic hyalinized arteries and arterioles. Occasionally, aneurysmally dilated arterioles and small arteries may be found. Death is generally due to compression and distortion of the midbrain, or hemorrhage into the ventricles. While deaths due to ruptured berry aneu-rysms or intracerebral hemorrhage are generally considered natural, in certain circumstances, they might be classified as homicide. Thus, if an individual ruptures an aneurysm during a fight in which physical violence is involved, the case should be classified as homicidal in manner. But, whether there are any criminal actions involved is something for the courts to decide, not the medical examiner.
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