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Lobar intracerebral hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Found by carers unresponsive, GCS 3. Past history of hypertension and ischemic stroke

Patient Data

Age: 90 years
Gender: Male

Large left-sided intracerebral hematoma.  It involves both deep and lobar structures (frontal and parietal lobes, basal ganglia).  Its epicenter is within the left frontal white matter.  There is ventricular hemorrhage but no subarachnoid hemorrhage. The hematoma is irregular but there are no finger-like projections. Within the hemorrhage are some areas of hypoattenuation (swirl sign/black hole sign).

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.

Severe periventricular low attenuation probably in keeping with small vessel disease +/- transpendymal CSF spread. 

Case Discussion

Large left 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 that aims to improve observer agreement. The epicenter of this hemorrhage (axial slice with the biggest ICH diameter) is within the left frontal white matter, so this hemorrhage would be classified as "uncertain but probably lobar".

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