Intracerebral hemorrhage (ICH) is the diagnosis. It is the second most common cause of stroke (ischemic stroke is the most common cause). Most cases of ICH are caused by hypertension, amyloid angiopathy, ruptured saccular aneurysm, and vascular malformation. The blood vessels that are involved in hypertensive ICH supply the pons and midbrain, thalamus, and the putamen and caudate. Hypertensive disease is thought to play a role in white matter disease. Cerebral amyloid angiopathy is usually asymptomatic but is a primary cause of ICH in the elderly. In this condition, amyloid deposits weaken the walls of the blood vessels and make them prone to bleeding. Nontraumatic causes of ICH include hemorrhagic infarction; septic embolism; mycotic aneurysm; brain tumor; bleeding disorders, liver disease, and chronic anticoagulation; central nervous system infection; moyamoya disease; vasculitis; cerebral hypoperfusion syndrome; reversible cerebral vasoconstriction syndromes; and illicit drugs, such as cocaine and amphetamines. Microbleeds are thought to be the cause of subclinical ICH, especially among the elderly. Microbleeds are associated with hypertension, diabetes mellitus, and cigarette smoking. Anticoagulation with warfarin increases the risk of ICH two- to five-fold, depending on the dose. The use of aspirin may be involved with a small absolute increased risk of ICH, and aspirin plus clopidogrel doubles the risk of ICH compared to the use of aspirin alone. Other risk factors for ICH include high alcohol intake, black race, lower cholesterol and low-density lipoprotein levels, and genetic variation. Some hypertensive hemorrhages occur with exertion or intense emotional activity. However, most cases take place during routine activity. The neurologic symptoms and signs usually increase gradually over several minutes or a few hours. Headache, vomiting, and a decreased level of consciousness develop if the hemorrhage becomes sufficiently large. Stupor or coma in ICH is an ominous sign. Neurologic signs vary based on the location of the hemorrhage. Computed tomography is the most widely used study to detect acute ICH, which is present almost immediately.
Atypical migraine (A) is a diagnosis of exclusion in this patient. More serious causes of a new-onset headache in any patient over age 50, such as intracranial hemorrhage and brain mass, must be ruled out. Myocardial infarction (C) is unlikely in this patient. While myocardial infarction can present with ECG abnormalities, the findings noted are associated with intracerebral hemorrhage (ICH). Troponin and beta-natriuretic peptide may be elevated as well. Symptoms and neurologic findings in subarachnoid hemorrhage (D) are usually maximal at onset, whereas ICH symptoms typically worsen gradually over the course of minutes to hours.