Lobar intracerebral hemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Found collapsed at home with right sided weakness, incomprehensible speech and headache. Last seen the previous day.

Patient Data

Age: 55 years
Gender: Female
CT

Large left parietal and occipital lobar hemorrhage involving cortex, subcortical white matter and periventricular white matter. There is subarachnoid and intraventricular hemorrhage. The hematoma has a lobulated contour without finger-like projections.

Mass effect from the hematoma and extensive perihaematomal edema result in marked midline shift.

Mild periventricular low attenuation in keeping with small vessel change. Mild cortical atrophy evident near vertex.

Case Discussion

Large left parietal and occipital lobar hemorrhage with the involvement of the cortex, and extension into the subarachnoid and intraventricular spaces. The hematoma contains lobulations without distinct finger-like projections.

Lobar intracerebral hemorrhage is frequently attributed to small vessel diseases (cerebral amyloid angiopathy or arteriolosclerosis). Differentiating lobar hemorrhage 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 CT shows subarachnoid hemorrhage but no finger-like projections from the hematoma. The patient did not possess an APOE e4 allele. Therefore they are intermediate risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral hemorrhage associated with cerebral amyloid angiopathy.

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PATHOLOGY: Postmortem performed 11 days after the ICH showed a large left sided cerebral hematoma involving the cortex and white matter.  There is diffuse subarachnoid hemorrhage.  No evidence of vascular malformation or underlying malignancy. There is small vessel disease throughout the white matter with lipohyalinosis. Immunohistochemistry showed no vascular or parenchymal amyloid.

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The hemorrhage is related to non-cerebral amyloid angiopathy small vessel disease arteriolosclerosis/lipohyalinosis.

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Case information

rID: 59357
Published: 5th Apr 2018
Last edited: 6th Apr 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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