Lobar haemorrhage

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 malformation1,9.

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

Aetiology

Often the cause of a lobar haemorrhage is never established and the causes, when found, are varied including 10,11:

CT

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.

CT angiography

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

CT perfusion

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

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 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:

Stroke and intracranial haemorrhage
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Article Information

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

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Cases and Figures

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    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 haemorrhage
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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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