Basal ganglia haemorrhage
Sudden onset left sided weakness
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Large right sided intracerebral haematoma. It involves both deep (basal ganglia) and lobar (frontal and temporal lobes) structures. Its epicentre is within the right basal ganglia. The haemorrhage extends into the intraventricular space.
There is significant mass effect relating to the haematoma and perihaematomal white matter oedema causing midline shift, compression of the third ventricle and partial effacement of ipsilateral cortical sulci.
Severe generalised cerebral volume loss. Mild periventricular low attenuation in keeping with small vessel change.
Heavily calcified right parafalcine extra-axial mass in keeping with a meningioma. No associated mass effect or parenchymal oedema.
Large right intracerebral haemorrhage. It involves both the deep and lobar structures, causes significant mass effect.
Identifying whether an ICH is lobar or deep is important as this in part determines the likely underlying aetiology 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, with a higher recurrent ICH rate). In cases such as this one, establishing whether an ICH is lobar or deep is difficult.
The Cerebral Haemorrhage Anatomical RaTing inStrument (CHARTS) is a recently published research tool which aims to improve observer agreement. The epicentre of this haemorrhage (axial slice with the biggest ICH diameter) is within the right basal ganglia, so this haemorrhage would be classified as "uncertain but probably deep".
Post mortem showed extensive right intracerebral haematoma centred on the right basal ganglia and extending into the periventricular white matter. Severe small vessel change and fibrinoid necrosis in relation to the area of haemorrhage. There is no significant beta amyloid deposition on immunohistochemistry, and no vascular malformation.