Left occipital lobar hemorrhage with the involvement of the cortex, 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 8 months after the ICH showed an old left occipital and parietal hematoma involving the cortex and white matter.  There is evidence of extension into the subarachnoid space. There is small vessel disease throughout the white and deep grey matter with lipohyalinosis and lacunar infarcts.  Immunohistochemistry showed widespread parenchymal amyloid deposition and localized amyloid angiopathy in the left occipital lobe. 

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This case highlights that the small vessel diseases underlying lobar ICH is often mixed. The hemorrhage may have been related to arteriolosclerosis or localized cerebral amyloid angiopathy.