Lobar haemorrhage is a subtype of intracranial haemorrhage, which generally carries a poor prognosis.
Primary lobar haemorrhages (usually due to cerebral amyloid angiopathy) are typically seen in elderly. Younger patients may also develop lobar haemorrhages, but in such cases they usually have an underlying lesion (e.g. cerebral arteriovenous malformation) 1,9.
Patients typically present with acute neurological deterioration, often with decreased GCS. Headache may be present.
Often the cause of a lobar haemorrhage is never established and the causes, when found, are varied including 10,11:
- secondary to drug use (e.g. cocaine, amphetamines)
- cerebral aneurysm: both saccular and mycotic
- arteriovenous malformation
- cerebral cavernoma
- brain tumour
- cerebral amyloid angiopathy
- bleeding disorders / coagulopathies / anticoagulation
- cerebral venous thrombosis
CT is usually the modality first obtained and demonstrates a hyperdense collection of blood, located superficially within the lobes of the brain (i.e., not in the basal ganglia). The haemorrhages vary widely in size from only a centimetre or so (often asymptomatic) to extremely large collections.
Extension into the subdural or subarachnoid and even intraventricular space (the latter is far more common in basal ganglia haemorrhages) may be seen.
It is becoming increasingly used in the workup of patients, not only to assess for an underlying abnormality, but also to evaluate for the presence of a spot, the so-called CTA spot sign, that is indicative of ongoing bleeding. The presence of such a spot sign correlates, not surprisingly, with a growth of the haemorrhage in the first few hours following the scan and is, again not surprisingly, associated with a poor outcome 1,4.
Recent studies have demonstrated the presence of the spot sign on dynamic-enhancement CT (DECT or CT perfusion) to be an even stronger predictor of hematoma expansion 5-6, i.e. the most robust factor in predicting outcome 7.
MRI is usually obtained when concern exists that the bleed if from an underlying region. Findings depend on the size and age of the bleed (see ageing blood on MRI).
In cases of primary lobar haemorrhage, multiple small areas of susceptibility-induced signal drop-out may be evident in keeping with previous micro haemorrhages, suggestive of cerebral amyloid angiopathy (CAA).
The presence of single lobar haemorrhage is still part of the Boston criteria for CAA.
Treatment and prognosis
Treatment depends on the age of the patient, and the size and location of the haematoma. Medical management is the mainstay, often palliative if the bleed is enormous, or the patient has significant pre-existing co-morbidities.
Surgical evacuation may be necessary.
Recombinant factor VII, extensively used in haemophiliacs is being investigated as a potential treatment for patients presenting early with intracranial haemorrhages. Although early studies suggested that it was promising in arresting haematoma growth and improving outcome, a larger follow-up trial has been unable to confirm this 2-3. An ongoing trial is looking at whether patients with a positive spot sign (established to correlated with early haematoma growth) may benefit.
The term lobar haemorrhage is often used to denote a primary haemorrhage. As such the differential includes:
- an underlying tumour (e.g. glioblastoma, cerebral metastasis)
- an underlying vascular malformation (e.g. cerebral arteriovenous malformation)
- haemorrhagic transformation of a cerebral infarct
- haemorrhagic transformation of the venous infarct
Stroke and intracranial haemorrhage
stroke and intracranial haemorrhage
- general discussions
- scoring and classification systems
- by region
- hemispheric infarcts
- frontal lobe infarct
- parietal lobe infarct
- temporal lobe infarct
- occipital lobe infarct
- internal capsule infarct
- ataxic hemiparesis syndrome: MCA perforators or basilar artery perforators
- lacunar infarct
- thalamic infarct
- cerebellar infarct
- midbrain infarct
- pontine infarct
- medullary infarct
- acute spinal cord ischaemia syndrome
- hemispheric infarcts
- by vascular territory
- anterior cerebral artery infarct
- anterior choroidal artery infarct
- anterior inferior cerebellar artery infarct
- basilar artery infarct
- middle cerebral artery infarct
- posterior cerebral artery infarct
- posterior inferior cerebellar artery infarct
- superior cerebellar artery infarct
- basal ganglia haemorrhage
- cerebellar haemorrhage
- cerebral contusions
- CTA spot sign
- haemorrhagic venous infarct
- haemorrhagic transformation of an ischaemic infarct
- hypertensive intracranial haemorrhage
- intraventricular haemorrhage (IVH)
- lobar haemorrhage
- pontine haemorrhage
- remote cerebellar haemorrhage
- extra-axial haemorrhage
- extradural haemorrhage (EDH)
- intralaminar dural haemorrhage
- subdural haemorrhage (SDH)
- subarachnoid haemorrhage (SAH)
- intra-axial haemorrhage
- ischaemic stroke
- 1. Emergency Radiology. Springer. (2007) ISBN:3540689087. Read it at Google Books - Find it at Amazon
- 2. Mayer SA. Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage. Stroke. 2007;38 (2): 763-767. Stroke (full text) - doi:10.1161/01.STR.0000254499.46122.22 - Pubmed citation
- 3. Mayer SA, Brun NC, Begtrup K et-al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N. Engl. J. Med. 2008;358 (20): 2127-37. doi:10.1056/NEJMoa0707534 - Pubmed citation
- 4. Demchuk AM, Dowlatshahi D, Rodriguez-Luna D et-al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol. 2012;11 (4): 307-14. doi:10.1016/S1474-4422(12)70038-8 - Pubmed citation
- 5. Sun SJ, Gao PY, Sui BB et-al. "Dynamic spot sign" on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage. Eur Radiol. 2013;23 (7): 1846-54. doi:10.1007/s00330-013-2803-4 - Pubmed citation
- 6. Koculym A, Huynh TJ, Jakubovic R et-al. CT perfusion spot sign improves sensitivity for prediction of outcome compared with CTA and postcontrast CT. AJNR Am J Neuroradiol. 2013;34 (5): 965-70, S1. doi:10.3174/ajnr.A3338 - Pubmed citation
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- 8. Kim SH, Jung HH, Whang K et-al. Which emphasizing factors are most predictive of hematoma expansion in spot sign positive intracerebral hemorrhage?. J Korean Neurosurg Soc. 2014;56 (2): 86-90. doi:10.3340/jkns.2014.56.2.86 - Free text at pubmed - Pubmed citation
- 9. Falcone GJ, Biffi A, Brouwers HB et-al. Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage. JAMA Neurol. 2013;70 (8): 988-94. doi:10.1001/jamaneurol.2013.98 - Free text at pubmed - Pubmed citation
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