Cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

2 week history of headaches, new onset dysphasia, reduced GCS

Patient Data

Age: 75 years
Gender: Male

Moderate left temporal lobar haemorrhage involving cortex and subcortical white matter. There is diffuse subarachnoid haemorrhage. The haematoma has an irregular outline with finger-like projections visible (best seen on the sagittal plane - see stack key images).

Focus of less marked hyperattenuation in the right temporal lobes, which is in keeping with a subacute haemorrhage.

No significant mass effect.

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

CT

Reduction in GCS during rehabilitation

New acute interecerebral haemorrhage in the left parietal lobe with associated subarachnoid haemorrhage. Less acute right parietal haematoma. Gliotic regions in the temporal lobes related to the previous haemorrhages.

Background small vessel change and moderate atrophy as before.

Case Discussion

Multiple lobar haemorrhages of differing ages with involvement of the cortex, extension into the subarachnoid spaces. The left temporal 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 acute haematoma. The patient did not possess 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.

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PATHOLOGY: Postmortem performed 2 months after the initial presentation showed several lobar haematomas of differing ages. Widespread subarachnoid haemorrhage is present. an extensive right cerebral haematoma. Immunohistochemistry showed extensive parenchymal and widespread vascular depositions. small vessel disease throughout the white matter in the form of lipohyalinosis and arteriolosclerosis, plus 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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Case information

rID: 58562
Published: 23rd Feb 2018
Last edited: 24th Feb 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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