Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues


Sudden onset headache with left sided weakness. Vomiting

Patient Data

Age: 75 years
Gender: Female

Right frontal lobar haemorrhage involving cortex, subcortical white matter and periventricular white matter. There is subarachnoid and intraventricular haemorrhage. The haematoma has multiple finger-like projections.

Mass effect from the haematoma and perihaematomal oedema with generalised effacement of the CSF spaces but no midline shift or hydrocephalus.

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

New left frontal intracerebral haematoma.  Subdural and subarachnoid haemorrhage present. Small volume ventricular haemorrhage. 

Right frontal gliosis with persistant sulcal effacement relating to the previous haemorrhage.

Interval left frontal croniotomy with linear low attenuation extending to the left lateral ventricle frontal horn in keeping with previous ventricular access device placement.

The CSF spaces remained effaced.

Case Discussion

Right frontal lobar haemorrhage with the involvement of the cortex, extension into the subarachnoid and intraventricular spaces. The haematoma contains multiple finger-like projections. Recurrent left frontal haematoma with subarachnoid and subdural haemorrhage.

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 initial 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 3 months after the ICH showed bifrontal cerebral haematomas with subarachnoid haemorrhage. Immunohistochemistry showed extensive parenchymal (Braak and Braak stage 3-4) and widespread vascular depositions. Moderate small vessel disease throughout the white matter with several lacunar infarcts.


This case highlights that the small vessel diseases underlying lobar ICH is often mixed. The haemorrhage may have been related to arteriolosclerosis or cerebral amyloid angiopathy.  The overall appearances are more consistent with cerebral amyloid angiopathy-associated haemorrhage.

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Case information

rID: 58566
Published: 23rd Feb 2018
Last edited: 24th Feb 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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