Lobar hemorrhage

Lobar hemorrhage is a subtype of intracranial hemorrhage, which generally carries a poor prognosis.

Primary lobar hemorrhages, usually due to cerebral amyloid angiopathy, are typically seen in elderly. Younger patients may also develop lobar hemorrhages, but in such cases they usually have an underlying lesion (e.g. cerebral arteriovenous malformation1,7.

Patients typically present with acute neurological deterioration, often with decreased GCS. Headache may be present.

Often the cause of a lobar hemorrhage is never established and the causes, when found, are varied including 8,9:

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 hemorrhages vary widely in size from only a centimeter or so (often asymptomatic) to extremely large hematomas.

Extension into the subdural or subarachnoid and even intraventricular space may be seen. Intraventricular extension is far more common in basal ganglia hemorrhages.

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 hemorrhage in the first few hours following the scan and is, again not surprisingly, associated with a poor outcome 1,2

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 3,4, i.e. the most robust factor in predicting outcome 7.

MRI is usually obtained when concern exists that the bleed is from an underlying region. Findings depend on the size and age of the bleed (see aging blood on MRI). 

In cases of primary lobar hemorrhage, multiple small areas of susceptibility-induced signal drop-out may be evident on GRE or SWI, in-keeping with previous cerebral microhemorrhages, suggestive of cerebral amyloid angiopathy.

The presence of single lobar hemorrhage is still part of the Boston criteria for CAA.

Treatment depends on the age of the patient, and the size and location of the hematoma. 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.

The term lobar hemorrhage is often used to denote a primary hemorrhage. As such the differential includes:

Stroke and intracranial haemorrhage
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Article information

rID: 13381
Tag: refs
Synonyms or Alternate Spellings:
  • Lobar haemorrhages
  • Lobar hemorrhage
  • Lobar hemorrhages

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Cases and figures

  • Case 1: with background cerebral amyloid angiopathy
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  • Case 2: in a patient on Warfarin
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  • Case 3: with subdural hemorrhage
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  • Case 4
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  • Case 5
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  • Case 6: with background cerebral amyloid angiopathy
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  • Case 7
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