Cerebral amyloid angiopathy-associated lobar intracerebral hemorrhage

Discussion:

Large right frontal lobar hemorrhage with the involvement of the cortex, extension into the subarachnoid spaces. The hematoma contains multiple finger-like projections. Recurrent bifrontal hemorrhages, with subarachnoid hemorrhage and finger0like projections

Lobar intracerebral hemorrhage is frequently attributed to small vessel diseases (cerebral amyloid angiopathy or arteriolosclerosis).  Differentiating lobar hemorrhage due to cerebral amyloid angiopathy and arteriolosclerosis is important due to differences in recurrent ICH and post-stroke dementia risk (higher with CAA-associated ICH).

The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral hemorrhage associated with cerebral amyloid angiopathy use CT features (presence of subarachnoid hemorrhage, finger-like projections arising from the ICH) and APOE e4 genotype (if available) to classify a patient as high, intermediate or low risk of CAA-associated ICH. The initial CT shows subarachnoid hemorrhage and finger-like projections from the hematoma. The patient did not possess an APOE e4 allele. Therefore they are high risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral hemorrhage associated with cerebral amyloid angiopathy.

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PATHOLOGY: Postmortem performed 3 months after the initial ICH showed an extensive right cerebral hematoma with older left and right frontal hemorrhages. There is subarachnoid hemorrhage. Immunohistochemistry showed extensive vascular amyloid depositions. 

 

The overall appearances are consistent with cerebral amyloid angiopathy-associated hemorrhage.

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