Cerebral amyloid angiopathy-associated lobar intracerebral hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain


Found collapsed, confused and vomiting.

Patient Data

Age: 85 years
Gender: Female

Large left occipital lobar hemorrhage involving cortex, subcortical white matter and periventricular white matter, and extending into the temporal lobe. There is overlying subarachnoid hemorrhage and subdural hemorrhage, plus intraventricular hemorrhage. The hematoma has multiple lobulations with finger-like projections evident (see stack key images).

Significant mass effect from the hematoma and perihaematomal edema resulting in effacement of ipsilateral cortical sulci and the left lateral ventricle and some midline shift.

Moderate periventricular low attenuation in keeping with small vessel change +/- transependymal CSF spread. Mild atrophy.

Case Discussion

Large left occipital lobar hemorrhage with the involvement of the cortex, extension into the subarachnoid, subdural and ventricular spaces. The hematoma contains multiple finger-like 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 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.


PATHOLOGY: Postmortem performed 10 days after the ICH showed a large left occipital hematoma with extensive subarachnoid hemorrhage. Immunohistochemistry showed extensive leptomeningeal and parenchymal vessels plus amyloid plaquesdepositions. Widespread small vessel disease throughout the white matter with lipohyalinosis and arteriolosclerosis.


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

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