Cerebral amyloid angiopathy-associated lobar intracerebral hemorrhage
Presentation
Found collapsed and unresponsive with right sided weakness
Patient Data
Large left frontal lobar hemorrhage involving cortex, subcortical white matter and periventricular white matter. There is overlying subarachnoid hemorrhage and a left subdural hemorrhage. The hematoma has lobulations with finger-like projections evident (best seen on the sagittal plane - see stack key image).
Significant mass effect from the hematoma and perihaematomal edema resulting in midline shift and obstructive hydrocephalus of the lateral ventricles.
Severe periventricular low attenuation in keeping with small vessel change +/- transependymal CSF spread. Mild atrophy. Chronic right occipital infarct
Case Discussion
Large left frontal lobar hemorrhage with the involvement of the cortex, extension into the subarachnoid and subdural 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 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 hemorrhage associated with cerebral amyloid angiopathy.
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PATHOLOGY: Postmortem performed one week after the ICH showed a large left frontal 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.
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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