A 64-year-old woman with a 15-year history of hypertension and chronic kidney disease stage 4 presents to the emergency department with acute onset severe frontal headache, confusion, and right-sided weakness. Her daughter reports she ran out of antihypertensive medications 2 weeks ago. Vital signs: BP 245/165 mmHg, HR 102 bpm, RR 20, temperature 37.3°C, SpO2 98% on room air. On neurologic examination, she has expressive aphasia and right hemiparesis. Non-contrast CT head shows a 3 cm acute intraparenchymal hemorrhage in the left basal ganglia with extension into the lateral ventricle. Laboratory studies: serum creatinine 3.1 mg/dL, BUN 68 mg/dL, hemoglobin 9.2 g/dL, platelets 245,000/μL, INR 1.0. No recent anticoagulation or antiplatelet use is documented. Which pathophysiologic mechanism most directly explains the hemorrhagic stroke in this patient?

1. A)Hypertensive microangiopathy with fibrinoid necrosis of penetrating arteriesGABARITO
2. B)Rupture of a saccular aneurysm at the circle of Willis due to chronic hypertension
3. C)Thrombotic microangiopathy from acute kidney injury causing endothelial damage
4. D)Amyloid angiopathy deposition in cortical vessels from chronic renal failure
5. E)Arterial dissection of the left middle cerebral artery from hypertensive surge