Presentation
Left-sided upper limb numbness.
Patient Data
Focal hemorrhage in the postcentral gyrus white matter on the right. No enhancement or abnormal vessels visible. Patchy chronic small vessel ischemic change.
Hemorrhage in the postcentral gyrus has no unexpected or solid enhancement and no abnormal vessels. Gradient echo images demonstrate extensive superficial hemosiderin and microhemorrhages strongly suggesting underlying cerebral amyloid angiopathy.
At the site of the previous hemorrhage involving the postcentral gyrus of the right hemisphere or focal region of hemosiderin staining with associated gliosis is noted.
Scattered throughout both cerebral hemispheres are numerous small punctate regions of susceptibility induced signal drop out, predominantly located peripherally (sparing the basal ganglia) and associated with extensive superficial siderosis. No significant posterior fossa siderosis can be identified. On phase-contrast images, these foci of old low signal do not demonstrate any features of calcification
White matter T2 hyperintensity associated with generalized volume loss and ex vacuo dilatation of the ventricle suggests chronic small vessel ischemic change. No intra- or extra-axial collection or mass identified.
Conclusion:
Peripheral supratentorial microhemorrhages with superficial siderosis strongly suggests the diagnosis of cerebral amyloid angiopathy.
Case Discussion
Cerebral amyloid angiopathy is the most common cause of primary lobar hemorrhages in the elderly and this distribution of microhemorrhages and hemosiderin staining is characteristic.