Basal ganglia haemorrhage
Found collapsed with left hemiparesis
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Large right sided intracerebral haematoma. It involves both deep and lobar structures. Its epicentre is within the right basal ganglia. The haemorrhage extends into the subarachnoid (right Sylvian fissure and right parietal region) and intraventricular spaces (frontal horn of the right lateral ventricle).
There is significant mass effect relating to the haematoma and perihaematomal white matter oedema causing midline shift, compression of the third ventricle and effacement of ipsilateral cortical sulci.
Large right intracerebral haemorrhage. It involves both the deep and lobar structures, causes significant mass effect and extends into the subarachnoid and intraventricular spaces.
Its size and involvement of the ventricular system, along with the patient's age and decreased GCS on admission are poor prognostic factors on the ICH score.
Identifying whether an ICH is lobar or deep is important as this in part determines the likely underlying aetiology as well as the prognosis (deep ICH are usually related to hypertensive arteriopathy, whereas lobar ICH can be due to hypertensive arteriopathy or cerebral amyloid angiopathy, with a higher recurrent ICH rate). In cases such as this one, establishing whether an ICH is lobar or deep is difficult.
The Cerebral Haemorrhage Anatomical RaTing inStrument (CHARTS) is a recently published research tool which aims to improve observer agreement. The epicentre of this haemorrhage (axial slice with the biggest ICH diameter) is within the right basal ganglia, so this haemorrhage would be classified as "uncertain but probably deep".
Post mortem showed massive disruption of the internal architecture of the right cerebrum, however the primary site of bleeding appeas to be within the right basal ganglia. There is background small vessel disease in the form of lipohyalinosis throughout the cerebrum, cerebellum and brainstem. No evidence of vascular malformation or malignancy. Very occasional cerebral amyloid angiopathy in the leptomeninges.
- Charidimou, A, Schmitt, A, Wilson, D et al. The Cerebral Haemorrhage Anatomical RaTing inStrument (CHARTS): development and assessment of reliability. J Neurol Sci. 2017; 372: 178–183
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- Rodrigues, MA, Samarasekera, N, Lerpiniere, C et al. The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy: model development and diagnostic test accuracy study. (published online Jan 10)Lancet Neurol. 2018; http://dx.doi.org/10.1016/S1474-4422(18)30006-1