Stress-related primary intracerebral hemorrhage - Autopsy clues to underlying mechanism

Background-Research into the causes of small-vessel stroke has been hindere d by technical constraints. Cases of intracerebral hemorrhage occurring in unusual clinical contexts suggest a causal role fur sudden increases in blo od pressure and/or cerebral blood flow. Case Description-We describe a fatal primary thalamic/brain stem hemorrhage occurring in the context of sudden emotional upset. At autopsy, the brain harbored several perforating artery fibrinoid lesions adjacent to and remot e from the hematoma as well as old lacunar infarcts and healed destructive small-vessel lesions. Conclusions-We postulate that the emotional upset caused a sudden rise in b lood pressure/cerebral blood flow, mediating small-vessel fibrinoid necrosi s and rupture. This or a related mechanism may underlie many small-vessel s trokes.