Cerebral amyloid angiopathy-associated lobar intracerebral hemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Found collapsed, reduced GCS, left sided weakness and facial droop

Patient Data

Age: 80 years
Gender: Female

Right frontal lobar hemorrhage involving cortex, subcortical white matter and periventricular white matter. There is subarachnoid but no intraventricular or subdural hemorrhage. The hematoma has multiple finger-like projections (see stack key images).

Significant mass effect from the hematoma and perihaematomal edema resulting in effacement of the frontal horn of the right lateral ventricle.

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

CT

Found collapsed in nursing home 3 months after the initial presentation

New large acute right frontal parenchymal hemorrhage with subarachnoid hemorrhage and finger-like projections.

Interval subacute left frontal parenchymal hemorrhage.

Gliosis in the inferior right frontal lobe at the site of the previuous parenchymal hemorrhage.

Case Discussion

Large right frontal lobar hemorrhage with the involvement of the cortex, extension into the subarachnoid spaces. The hematoma contains multiple finger-like projections. Recurrent bifrontal hemorrhages, with subarachnoid hemorrhage and finger0like projections

Lobar intracerebral hemorrhage is frequently attributed to small vessel diseases (cerebral amyloid angiopathy or arteriolosclerosis).  Differentiating lobar hemorrhage 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 hemorrhage associated with cerebral amyloid angiopathy use CT features (presence of subarachnoid hemorrhage, 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 hemorrhage and finger-like projections from the hematoma. The patient did not possess an APOE e4 allele. Therefore they are high risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral hemorrhage associated with cerebral amyloid angiopathy.

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PATHOLOGY: Postmortem performed 3 months after the initial ICH showed an extensive right cerebral hematoma with older left and right frontal hemorrhages. There is subarachnoid hemorrhage. Immunohistochemistry showed extensive vascular amyloid depositions. 

 

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

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Case information

rID: 58569
Published: 23rd Feb 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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