Basal ganglia hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Sudden onset left sided weakness

Patient Data

Age: 90 years
Gender: Female
ct

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

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

Severe generalized cerebral volume loss. Mild periventricular low attenuation in keeping with small vessel change.

Heavily calcified right parafalcine extra-axial mass in keeping with a meningioma. No associated mass effect or parenchymal edema.

Case Discussion

Large right intracerebral hemorrhage. It involves both the deep and lobar structures, causing 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 right basal ganglia, so this hemorrhage would be classified as "uncertain but probably deep".

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PATHOLOGY: Post mortem showed extensive right intracerebral hematoma centered on the right basal ganglia and extending into the periventricular white matter. Severe small vessel change and fibrinoid necrosis in relation to the area of hemorrhage. There was no significant beta amyloid deposition on immunohistochemistry, and no vascular malformation.

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