Cerebral amyloid lobar hemorrhage

Case contributed by Assoc Prof Frank Gaillard

Presentation

Right sided weakness.

Patient Data

Age: 90 years
Gender: Female

Left parietal intraparenchymal lobar hematoma with local mass effect causing overlying sulcal effacement and distortion of the posterior horn of the lateral ventricle. Patchy deep and periventricular white matter hypodensity most likely represents chronic small vessel ischemia. 

MRI months later

MRI

Left parietal lobe and volume loss, T2 FLAIR white matter hyperintensity, and gyriform hemosiderin staining representing site of resolving intraparenchymal hematoma. Diffuse cerebral and cerebellar volume loss within normal limits for patient of this age. Confluent periventricular white matter and subcortical T2 and FLAIR hyperintensity in keeping with chronic small vessel disease.

Additionally, susceptibility weighted sequences demonstrate multiple punctate foci of blooming in both cerebral hemispheres (with predominance at the grey-white matter interface), brainstem and right cerebral hemisphere. 

Conclusion: Diffuse punctate foci of blooming artefact on susceptibility weighted sequences is highly suggestive of cerebral amyloid angiopathy

Case Discussion

Lobar hemorrhage in a elderly individual is most frequently due to cerebral amyloid angiopathy, especially if no obvious underlying mass can be identified on CT. The presence of peripheral punctate regions of signal loss are supportive of this diagnosis. 

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