Small vessel disease: hypertensive and amyloid hemorrhage
- Lesion
Years of high blood pressure or amyloid damage the brain's tiny arteries, which then bleed or block, causing strokes and dementia.
What it is
Small penetrating arteries and arterioles are the targets of chronic hypertension, which thickens their walls (hyaline arteriolosclerosis) and weakens them. Blocked arterioles give lacunar infarcts; ruptured ones give deep intracerebral hemorrhage. In older adults, beta-amyloid deposited in cortical and leptomeningeal vessels (cerebral amyloid angiopathy) makes them brittle and causes lobar hemorrhages. Accumulated small infarcts and white matter damage cause vascular cognitive impairment.
Structure
- Acute hemorrhage: a clot that destroys and compresses tissue; old hemorrhage leaves a slit-like cavity with hemosiderin-laden macrophages and gliosis.
- Slit hemorrhages are small old bleeds seen as rust-coloured slits; hypertensive encephalopathy shows diffuse edema, petechiae and fibrinoid necrosis of arterioles.
- CADASIL: granular osmiophilic material in the basement membrane of vascular smooth muscle on electron microscopy.
Hypertensive vs amyloid hemorrhage
| Feature | Hypertensive hemorrhage | Cerebral amyloid angiopathy |
|---|---|---|
| Age | Middle age and older | Mostly older adults |
| Site | Deep: putamen, thalamus, pons, cerebellum | Lobar: cortex and subcortical white matter |
| Vessel change | Hyaline arteriolosclerosis, microaneurysms | Amyloid in media and adventitia, double-barrel lumen |
| Stain | No special stain | Congo red (apple-green birefringence), beta-amyloid IHC |
| Pattern | Usually a single large bleed | Recurrent bleeds and many microbleeds |
Clinical notes
- Lacunar strokes give pure motor, pure sensory or ataxic syndromes, without cortical signs such as aphasia.
- Controlling blood pressure is the main way to prevent hypertensive bleeds and lacunes.
Test yourself
Think of the answer, then tap the question to see it.
Which is the most common site of hypertensive intracerebral hemorrhage?
The putamen (basal ganglia), followed by the thalamus, pons and cerebellum.
What is a lacune?
A small cavitary infarct from occlusion of a penetrating arteriole, usually in deep grey matter, internal capsule or pons.
Which stain shows the vessel deposits of cerebral amyloid angiopathy?
Congo red, which gives apple-green birefringence under polarised light; immunostains confirm beta-amyloid.
Which gene is mutated in CADASIL?
NOTCH3, an autosomal dominant arteriopathy of small vessels that causes strokes and dementia in mid-life.
Elsewhere in DurgiPedia
Connections
Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.
Sources: Intracerebral Hemorrhagic Stroke (StatPearls (NCBI Bookshelf), 2026).
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Representative model, for educational purposes only.