Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues


Acute onset left sided weakness with slurred speech

Patient Data

Age: 85 years
Gender: Female

Right frontal lobar haemorrhage involving cortex and subcortical white matter. There is adjacent subarachnoid but no intraventricular or subdural haemorrhage. The haematoma has an irregular lobulated contour with finger-like projections (best seen on the sagittal plane - see stack key images).

The haematoma and perihaematomal oedema result in some midline shift and partial effacement of the right lateral ventricle.

Moderate periventricular low attenuation in keeping with small vessel change. Marked cortical atrophy.

Case Discussion

Right frontal lobar haemorrhage with the involvement of the cortex and extension into the subarachnoid. The haematoma contains multiple finger-like projections.

Lobar intracerebral haemorrhage is frequently attributed to small vessel diseases (cerebral amyloid angiopathy or arteriolosclerosis).  Differentiating lobar haemorrhage due to cerebral amyloid angiopathy and arteriolosclerosis is important due to differences in recurrent ICH and post-stroke dementia risk (higher with CAA-associated ICH).

The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy use CT features (presence of subarachnoid haemorrhage, finger-like projections arising from the ICH) and APOE e4 genotype (if available) to classify a patient as high, intermediate or low risk of CAA-associated ICH. The CT shows subarachnoid haemorrhage and finger-like projections from the haematoma. The patient also possessed at least one APOE e4 allele. Therefore they are high risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy.


PATHOLOGY: Postmortem performed 1 month after the ICH showed a large right cerebral haematoma in the posterior frontal lobe with extension into the subarachnoid space. Immunohistochemistry showed vascular deposits mostly in the leptomeningal vessels and parenchyma (Braak and Braak stage 3). Mild small vessel disease throughout the white matter but no lacunar infarcts.


The overall appearances are more consistent with cerebral amyloid angiopathy-associated haemorrhage.

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Case information

rID: 58565
Published: 23rd Feb 2018
Last edited: 24th Feb 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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