Intracerebral hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Sudden deterioration in GCS from 15 to 4 with left sided weakness

Patient Data

Age: 95 years
Gender: Female
ct

Large right sided intracerebral hematoma.  It involves both deep and lobar structures (frontal lobe, basal ganglia and midbrain).  Its epicenter is difficult to determine but probably within the right frontal periventricular white matter.  There is subarachnoid and ventricular extension. The hematoma is irregular but there are no finger-like projections

There is significant mass effect relating to the hematoma and perihaematomal white matter edema causing midline shift, compression of the ipsilateral lateral ventricle and third ventricle and effacement of ipsilateral cortical sulci. There is dilatation of the temporal horns of the lateral ventricles in keeping with hydrocephalus.

Moderate periventricular low attenuation probably in keeping with small vessel disease +/- transpendymal CSF spreading.  Moderate cortical atrophy.

Case Discussion

Large right intracerebral hemorrhage.  It involves both the deep and lobar structures, causes significant mass effect and extends into the subarachnoid space.

 

Identifying whether an ICH is lobar or deep is important as this in part determines the likely underlying etiology as well as the prognosis (deep ICH are usually related to hypertensive arteriopathy, whereas lobar ICH can be due to hypertensive arteriopathy or cerebral amyloid angiopathy, which has a higher recurrent ICH rate). In cases such as this one, establishing whether an ICH is lobar or deep is difficult.

 

The Cerebral Hemorrhage Anatomical RaTing inStrument (CHARTS) is a recently published research tool which aims to improve observer agreement. The epicenter of this hemorrhage (axial slice with the biggest ICH diameter) is difficult to determine but probably within the right frontal periventricular white matter.  so this hemorrhage would be classified as "uncertain but probably lobar".

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PATHOLOGY

The patient died one day after the ICH and underwent a post mortem. This showed an acute, extensive right frontal intracerebral hemorrhage with subarachnoid and ventricular hemorrhage. There is extensive small vessel disease in the form of lipohyalinosis and arteriolosclerosis with several lacunar infarcts.  There is no amyloid angiopathy on immunohistochemistry

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