Cerebral amyloid angiopathy-associated lobar intracerebral hemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Found collapsed, GCS 6

Patient Data

Age: 65 years
Gender: Male

Large right frontal lobar hemorrhage involving cortex and subcortical white matter. There is localized subarachnoid hemorrhage. The hematoma has multiple finger-like projections.

Significant mass effect from the hematoma and perihaematomal edema resulting in midline shift.

Mild periventricular low attenuation may represent small vessel change or transependymal CSF spread.

Case Discussion

Large right frontal lobar hemorrhage with the involvement of the cortex, extension into the subarachnoid space. 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 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 2 months after the ICH showed an extensive right cerebral hematoma with subarachnoid extension. There was extensive cerebral amyloid angiopathy plus some small vessel disease.

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Case information

rID: 58756
Published: 5th Mar 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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