Basal ganglia hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain


Collapse with right sided weakness

Patient Data

Age: 50 years
Gender: Male

Large left sided intracerebral hematoma. It involves both deep (basal ganglia) and lobar (frontal lobe) structures. Its epicenter is within the left basal ganglia. The hemorrhage extends into the intraventricular space.

There is significant mass effect relating to the hematoma causing midline shift, compression of the third ventricle and partial effacement of ipsilateral cortical sulci.

Case Discussion

Large left intracerebral hemorrhage.  It involves both the deep and lobar structures, causes significant mass effect.

 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 left basal ganglia, so this hemorrhage would be classified as "uncertain but probably deep".

Post mortem showed extensive left sided hematoma centered around the left deep grey structures. There is extensive small vessel disease including an old lacunar infarct in the right basal ganglia. There is no significant beta amyloid deposition on immunohistochemistry, and no vascular malformation or tumor.

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