Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Found collapsed, reduced GCS, left sided weakness and facial droop

Patient Data

Age: 80 years
Gender: Female

Right frontal lobar haemorrhage involving cortex, subcortical white matter and periventricular white matter. There is subarachnoid but no intraventricular or subdural haemorrhage. The haematoma has multiple finger-like projections (see stack key images).

Significant mass effect from the haematoma and perihaematomal oedema resulting in effacement of the frontal horn of the right lateral ventricle.

Moderate periventricular low attenuation in keeping with small vessel change. Mild atrophy.

CT

Found collapsed in nursing home 3 months after the initial presentation

New large acute right frontal parenchymal haemorrhage with subarachnoid haemorrhage and finger-like projections.

Interval subacute left frontal parenchymal haemorrhage.

Gliosis in the inferior right frontal lobe at the site of the previuous parenchymal haemorrhage.

Case Discussion

Large right frontal lobar haemorrhage with the involvement of the cortex, extension into the subarachnoid spaces. The haematoma contains multiple finger-like projections. Recurrent bifrontal haemorrhages, with subarachnoid haemorrhage and finger0like projections

Lobar intracerebral haemorrhage is frequently attributed to small vessel diseases (cerebral amyloid angiopathy or arteriolosclerosis).  Differentiating lobar haemorrhage 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 haemorrhage associated with cerebral amyloid angiopathy use CT features (presence of subarachnoid haemorrhage, 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 subarachnoid haemorrhage and finger-like projections from the haematoma. The patient did not possess an APOE e4 allele. Therefore they are high risk for CAA-associated ICH on the Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy.

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PATHOLOGY: Postmortem performed 3 months after the initial ICH showed an extensive right cerebral haematoma with older left and right frontal haemorrhages. There is subarachnoid haemorrhage. Immunohistochemistry showed extensive vascular amyloid depositions. 

 

The overall appearances are consistent with cerebral amyloid angiopathy-associated haemorrhage.

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Case information

rID: 58569
Published: 23rd Feb 2018
Last edited: 24th Feb 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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