Presentation
Found unresposive
Patient Data
Large left sided intracerebral hematoma. It involves both deep (basal ganglia) and lobar (frontal and temporal lobes) 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 and perihaematomal white matter edema causing midline shift, compression of the third ventricle and partial effacement of ipsilateral cortical sulci. The temporal horns of the lateral ventricules are dilated in keeping with hydrocephalus.
Mild generalized cerebral volume loss. Mild periventricular low attenuation in keeping with small vessel change.
Case Discussion
Large left 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 left basal ganglia. Its configuration is also typical of a deep/basal ganglia hemorrhage. Therefore this hemorrhage would be classified as "uncertain but probably deep". The likely underlying etiology is "hypertensive" arteriopathy (non-amyloid small vessel disease).
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