Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage
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Large right frontal lobar haemorrhage involving cortex, subcortical white matter and periventricular white matter. There is subarachnoid and intraventricular haemorrhage. The haematoma has multiple finger-like projections (see stack key images).
Significant mass effect from the haematoma and perihaematomal oedema resulting in midline shift, obstructive hydrocephalus of the lateral ventricles and partial effacement of the suprasellar cistern.
Moderate periventricular low attenuation may represent small vessel change or transependymal CSF spread. Mild atrophy.
Large right frontal lobar haemorrhage with the involvement of the cortex, extension into the subarachnoid and intraventricular spaces. The haematoma contains multiple finger-like 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 also possessed at least one 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.
PATHOLOGY: Postmortem performed 14 months after the ICH showed an extensive right cerebral haematoma. Immunohistochemistry showed extensive parenchymal and widespread vascular depositions. Severe small vessel disease throughout the white matter with several lacunar infarcts.
This case highlights that the small vessel diseases underlying lobar ICH is often mixed. The haemorrhage may have been related to arteriolosclerosis or cerebral amyloid angiopathy. The overall appearances are more consistent with cerebral amyloid angiopathy-associated haemorrhage.
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