Basal ganglia hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Found collapsed with left hemiparesis

Patient Data

Age: 90 years
Gender: Male
ct

Large right sided intracerebral hematoma.  It involves both deep and lobar structures.  Its epicenter is within the right basal ganglia. The hemorrhage 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 hematoma and perihaematomal white matter edema causing midline shift, compression of the third ventricle and effacement of ipsilateral cortical sulci.

Case Discussion

Large right intracerebral hemorrhage.  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 etiology 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 Hemorrhage Anatomical RaTing inStrument (CHARTS) is a recently published research tool which aims to improve observer agreement. The epicenter of this hemorrhage (axial slice with the biggest ICH diameter) is within the right basal ganglia, so this hemorrhage would be classified as "uncertain but probably deep".

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PATHOLOGY: Post mortem showed massive disruption of the internal architecture of the right cerebrum, however the primary site of bleeding appears 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.

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