Lobar intracerebral hemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Sudden onset numbness of left arm followed by left leg. Developed slurred speech before GCS dropped. Previous ischaemic infarct

Patient Data

Age: 80 years
Gender: Male
CT

Rright frontal lobar hemorrhage involving cortex, subcortical white matter and periventricular white matter. There is intraventricular hemorrhage but no subarachnoid or subdural extension. The hematoma has a lobulated contour without finger-like projections.

Mass effect from the hematoma and perihaematomal edema resulting in mild midline shift.

Mild periventricular low attenuation in keeping with small vessel change. Mild cortical atrophy evident near vertex. Gliosis in the left MCA and right PCA territories consistent with previous infarcts.

Case Discussion

Right frontal lobar hemorrhage with the involvement of the cortex, extension into the intraventricular space. The hematoma contains lobulations without distinct finger-like projections.  There is no subarachnoid hemorrhage

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 no subarachnoid hemorrhage and no finger-like projections from the hematoma. The patient did not possess an APOE e4 allele. Therefore they are low 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 2 weeks after the ICH showed a right frontal hematoma. The hematoma does not appear to extend through the cortical surface. Old left MCA territory infarct. There is small vessel disease throughout the white matter with lipohyalinosis without lacunar infarcts. Immunohistochemistry showed low level parenchymal amyloid but no vascular amyloid. 

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The histopathological examination is consistent with a primary small vessel/hypertensive intracerebral hemorrhage.

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Case information

rID: 59360
Published: 5th Apr 2018
Last edited: 7th Apr 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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