Lobar intracerebral hemorrhage

Discussion:

Large right intracerebral hemorrhage.  It involves both the deep and lobar structures, causes significant mass effect and extends into the subarachnoid space.

 Identifying whether an ICH is lobar or deep is important as this in part determines the likely underlying etiology as well as the prognosis (deep ICH are usually related to hypertensive arteriopathy, whereas lobar ICH can be due to hypertensive arteriopathy or cerebral amyloid angiopathy, which has a higher recurrent ICH rate). In cases such as this one, establishing whether an ICH is lobar or deep is difficult.

The Cerebral Hemorrhage Anatomical RaTing inStrument (CHARTS) is a recently published research tool which aims to improve observer agreement. The epicenter of this hemorrhage (axial slice with the biggest ICH diameter) is within the right parietal white matter, so this hemorrhage would be classified as "uncertain but probably lobar".

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PATHOLOGY

The patient died one day after the ICH and underwent a post mortem. This showed an acute, extensive right intracerebral hemorrhage with subarachnoid hemorrhage. There is extensive small vessel disease in the form of lipohyalinosis and arteriolosclerosis with several lacunar infarcts.  There is no amyloid angiopathy on immunohistochemistry

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