Lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Fall, headache

Patient Data

Age: 95 years
Gender: Female

The images are degraded by patient positioning. There is a small ovoid acute haemorrhage in the right frontal lobe. This involves the subcortical white matter as well as the cortex. There is no subarachnoid, subdural or extradural haemorrhage. No significant mass effect.

Tiny subcortical haemorrhage in the left frontal white matter.

Moderate periventricular low attenuation in keeping with small vessel change. Mild central and moderate cortical cerebral volume loss.

Case Discussion

Small right frontal lobar haemorrhage without involvement of the cortical surface or extension into the subarachnoid space. Background changes of small vessel disease and moderate atrophy. The location of the haemorrhage is not typical for a traumatic ICH and likely represents a primary ICH.

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 uses 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. This patient shows no subarachnoid haemorrhage, no finger-like projections and no APOE e4 allele and is therefore low risk for CAA-associated ICH on the Edinburgh criteria.

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PATHOLOGY: Post mortem showed extensive beta amyloid in the neocortex and hippocampus which is predominantly parenchymal in keeping with Alzheimer disease (Braak and Braak stage 2) with very little vascular amyloid (cerebral amyloid angiopathy). Background small vessel disease is present but mild. No tumour or vascular malformation. The cause of the haemorrhage is unclear.

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Case information

rID: 58353
Published: 14th Feb 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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