Presentation
History of old strokes.
Patient Data
Right occipito-pareital lobar cortical and left basal ganglia old hematomas.
Multiple lobar (cortical), deep basal ganglia and brainstem and cerebellar microbleeds.
Small vessel arteriosclerotic leukoencephalopathy with multiple old lacunar infarcts.
Case Discussion
The main causes of primary intracerebral hemorrhage are cerebral amyloid angiopathy and hypertensive small vessel disease. Cerebral amyloid mainly affects the cortical and leptomeningeal vessels hence causes lobar bleeds and cortical superficial siderosis, whereas hypertensive small vessel disease mainly affects the deep perforating arterioles hence causes deep hemorrhage.
Patients with intracerebral hemorrhage/microbleeds in both lobar and deep hemispheric brain regions (mixed intracerebral hemorrhage) are commonly encountered in clinical practice.
Previous studies suggest that hypertensive small vessel disease could cause lobar microbleeds. The pathologic process underlying mixed intracerebral hemorrhage may be a severe vasculopathy -similar to hypertensive microangiopathy- caused by risk factors such as hypertension and diabetes mellitus, or more of a combination of both CAA and HTN-SVD, but this issue is unresolved at that time.
In a study 1, patients with mixed intracerebral hemorrhage seemed to have a more pronounced classic vascular risk factor burden (more lacunes, higher creatinine) than patients with cerebral amyloid but a vascular risk factor profile similar to those with hypertensive microangiopathy, whereas compared to patients with hypertensive microangiopathy, those with mixed ICH were older with more lacunes and microbleeds.