Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Sudden reduction in mobility with right sided weakness

Patient Data

Age: 80 years
Gender: Male

Acute left parietal haematoma involving the cortex and subcortical white matter. There is no definite subarachnoid haemorrhage, and no subdural, extradural or intraventricular component. The haemtoma has a slightly lobulated contour and fluid level but no finger-like projections.

Mass effect on the adjacent lateral ventricle and overlying cortical sulci.

Severe periventricular low attenuation in keeping with small vessel disease.  Severe generalised cerebral volume loss.

Case Discussion

Left parietal lobar haemorrhage with involvement of the cortex. There is no extension into the subarachnoid space or ventricles. Background changes of severe small vessel disease (periventricular low attenuation) and atrophy.

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 initial CT shows no subarachnoid haemorrhage or finger-like projections from the haematoma. The patient possessed at least one APOE e4 allele. Therefore they are intermediate risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy.

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PATHOLOGY: Post mortem showed left parietal haematomata with extension into the subarachnoid space. There is small vessel disease throughout the white matter with enlarged perivascular spaces and rarefaction, lipohyalinosis and arteriolosclerosis. Widespread amyloid angiopathy with concentric splitting of some vessels.  There is also extensive parenchymal amyloid. 

 

The pathology demonstrates extensive cerebral amyloid angiopathy and arteriolosclerosis, both of which could result in the haemorrhage.  The distribution of haemorrhage is more suggestive of cerebral amyloid angiopathy

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Case information

rID: 58530
Published: 22nd Feb 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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