[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [General pathology](https://durgical.com/en/general-pathology/) › [Central nervous system](https://durgical.com/en/general-pathology/areas/cns/) › Small vessel disease: hypertensive and amyloid hemorrhage

# 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.

Updated Nov 12, 2026

## Key points

- Hypertensive hemorrhage sites: putamen (most common), thalamus, pons and cerebellar hemispheres.
- Charcot-Bouchard microaneurysms on small perforating arteries are a classic but debated source of hypertensive bleeding.
- Lacunes: small cavitary infarcts (under about 15 millimetres) in the basal ganglia, internal capsule, thalamus and pons.
- Cerebral amyloid angiopathy: beta-amyloid in vessel walls, congophilic with apple-green birefringence, gives lobar bleeds and microbleeds; linked to APOE ε4 and ε2.
- Vascular dementia: multiple infarcts or diffuse white matter damage (Binswanger type); CADASIL is the inherited NOTCH3 form.

## 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](https://durgical.com/en/conditions/intracerebral-haemorrhage/) | 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.

## Memory aid

Pressure bursts the deep pipes (putamen, thalamus, pons, cerebellum); amyloid cracks the surface pipes (lobar bleeds).

## 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.

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## Elsewhere in DurgiPedia

- [Cerebral blood flow, brain metabolism and intracranial pressure](https://durgical.com/en/physiology/cerebral-blood-flow-brain-metabolism-and-intracranial-pressure/)

## Connections

## Related 7

- [Cerebral infarction](https://durgical.com/en/general-pathology/cerebral-infarction/)
- [Berry aneurysm and subarachnoid hemorrhage](https://durgical.com/en/general-pathology/berry-aneurysm-and-subarachnoid-hemorrhage/)
- [Vascular malformations of the brain](https://durgical.com/en/general-pathology/vascular-malformations-of-the-brain/)
- [Alzheimer disease: plaques and tangles](https://durgical.com/en/general-pathology/alzheimer-disease-plaques-and-tangles/)
- [Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does](https://durgical.com/en/general-pathology/hemorrhage-petechiae-purpura-ecchymosis-hematoma-and-what-blood-loss-does/)
- [Arteriosclerosis: the three patterns](https://durgical.com/en/general-pathology/arteriosclerosis-the-three-patterns/)
- [Hypertension: mechanisms](https://durgical.com/en/general-pathology/hypertension-mechanisms/)

## Related conditions 7

- [Intracerebral haemorrhage](https://durgical.com/en/conditions/intracerebral-haemorrhage/)
- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Hypertensive emergency and urgency](https://durgical.com/en/conditions/hypertensive-emergency-and-urgency/)
- [Vascular dementia](https://durgical.com/en/conditions/vascular-dementia/)
- [Alzheimer disease](https://durgical.com/en/conditions/alzheimer-disease/)
- [Amyloidosis](https://durgical.com/en/conditions/amyloidosis/)
- [Dementia (major neurocognitive disorder)](https://durgical.com/en/conditions/dementia/)

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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](https://www.ncbi.nlm.nih.gov/books/NBK553103/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/general-pathology/small-vessel-disease-hypertensive-and-amyloid-hemorrhage/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/small-vessel-disease-hypertensive-and-amyloid-hemorrhage/