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Lobar intracerebral hemorrhage

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Found on bathroom floor, unable to get up

Patient Data

Age: 70 years
Gender: Female

Small acute left occipital hematoma involving subcortical white matter. There is no subarachnoid, subdural, extradural or intraventricular component. The haemtoma has a regular contour without finger-like projections. Tiny further hemorrhage in the left periventricular white matter.

No significant mass effect.

Severe periventricular low attenuation in keeping with small vessel disease.  Moderate generalized cerebral volume loss.

Case Discussion

Left occipital lobar hemorrhage without extension into the subarachnoid space or finger-like projections. Tiny further periventricular hemorrhage. Background changes of severe small vessel disease and moderate atrophy.

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 Edinburgh CT and genetic diagnostic criteria for lobar intracerebral hemorrhage associated with cerebral amyloid angiopathy uses CT features (presence of subarachnoid hemorrhage, 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. The initial CT shows no subarachnoid hemorrhage or finger-like projections from the hematoma. The patient did not possess at least one 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: Post mortem one year later showed a large acute left sided hemorrhage and old left occipital hematoma.  There is extensive small vessel disease throughout the white matter in the form of lipohyalinosis and arteriolosclerosis.  Immunohistochemistry shows patchy meningeal vascular amyloid.  The hemorrhages are likely related to non-CAA small vessel disease

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