Basal ganglia hemorrhage

Case contributed by Mark Rodrigues
Diagnosis almost certain


Collapse and unresponsive. Vomiting. Not moving left side of body.

Patient Data

Age: 65 years
Gender: Male

Large right-sided intracerebral hematoma. It involves both deep (basal ganglia) and frontal lobar 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 causing midline shift, compression of the third ventricle and partial effacement of ipsilateral cortical sulci. The temporal horns of the lateral ventricles are dilated in keeping with hydrocephalus.

CT angiogram shows no aneurysm or arteriovenous malformation. A small focus of hyperattenuation is present within the center of the hematoma in keeping with a spot sign.

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. 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).

The CTA spot sign is a predictor of hematoma expansion

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