Presentation
Found collapsed on bathroom floor. Not moving left side.
Patient Data
Right sided intracerebral hematoma. It involves both deep (basal ganglia) and lobar (frontal white matter) structures. Its epicenter is within the right basal ganglia. There is a tiny volume of hemorrhage in the occipital horn of the right lateral ventricle. The hemorrhage does not extend into the subarachnoid space.
There is no significant mass effect relating to the hematoma.
Severe generalized cerebral volume loss. Moderate periventricular low attenuation in keeping with small vessel change.
Case Discussion
Right intracerebral hemorrhage which involves both the deep and lobar structures.
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 superior right 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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PATHOLOGY
The patient underwent autopsy a few weeks after the hemorrhage. This showed a hemorrhage centered on the right external capsule. There was widespread small vessel disease (lipohyalinosis, enlarged perivascular spaces, lacunar infarcts). There was extensive parenchymal amyloid deposition in keeping with Alzheimer's disease but no amyloid angiopathy.
The findings show a deep hemorrhage associated with non-cerebral amyloid angiopathy small vessel disease,
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