Presentation
Collapse, vomiting, reduced consciousness
Patient Data
Large lobar intracerebral hematoma involving the right temporal lobe with a small amount of surrounding perihaematomal edema. Subarachnoid hemorrhage in the overlying sulci as well as the basal cisterns. Right subdural hematoma. Small volume intraventricular hemorrhage in the fourth ventricle.
There is diffuse effacement of the cortical sulci, effacement of the right lateral ventricle, marked leftward midline shift, right uncal and central transtentorial herniation and effacement of the basal cisterns. Tonsillar herniation is present. No hydrocephalus.
Small ovoid lesion immediately inferior to the hematoma, adjacent to the expected location of the middle cerebral artery is suggestive of an aneurysm, which is the likely cause of the hemorrhage.
Low attenuation in the inferomedial right parietal and occipital lobes with loss of grey-white matter differentiation is concerning for an acute posterior cerebral artery infarct. The brainstem is difficult to assess due to streak artefact but its attenuation also appears reduced, which is suggestive of infarct.
Case Discussion
- Macrovascular lesions, such as arterial aneurysms, underlie 10-15% of spontaneous intracerebral hemorrhage.
- Early identification of such abnormalities is important to allow appropriate treatment.
- Specific features on non contrast CT of an underlying macrovascular lesion include enlarged vessels or calcifications along margins of ICH 1.
- Subarachnoid hemorrhage in the basal cisterns and ICH location adjacent to the circle of Willis are other risk factors for an underlying macrovascular lesion.
This case also highlights consequences of raised intracranial pressure including brain herniation.
The patient was too agitated to undergo CT angiography at the time of the diagnostic CT, and died shortly later.