Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage
Sudden onset headache, nausea and vomiting. Subsequent left arm and leg weakness
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Large right lobar haemorrhage which is centred in the occipital lobe, but also involves the temporal and parietal lobes. It involves cortex, subcortical white matter and periventricular white matter. There is subarachnoid but no intraventricular or subdural haemorrhage. The haematoma has multiple finger-like projections (see stack key images).
Significant mass effect from the haematoma and perihaematomal oedema resulting in midline shift, obstructive hydrocephalus of the lateral ventricles and partial effacement of the ipsilateral cortical sulci.
Mild periventricular low attenuation may represent small vessel change or transependymal CSF spread. Mild atrophy.
Large right occipito-parieto-temporal lobar haemorrhage with the involvement of the cortex, extension into the subarachnoid. The haematoma contains multiple finger-like projections.
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 Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy use CT features (presence of subarachnoid haemorrhage, 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 haemorrhage and finger-like projections from the haematoma. 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 haemorrhage associated with cerebral amyloid angiopathy.
PATHOLOGY: Postmortem performed 5 days after the ICH showed a large right occipital haematoma with extension into the subarachnoid and subdural spaces. Immunohistochemistry showed extensive parenchymal and widespread vascular depositions. Mild small vessel disease throughout the white matter with enlarged perivascular spaces.
The appearances are in keeping with a cerebral amyloid angiopathy-associated haemorrhage
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