Lobar intracerebral haemorrhage

Case contributed by Dr Mark Rodrigues

Presentation

Found on bathroom floor, unable to get up

Patient Data

Age: 70 years
Gender: Female

Small acute left occipital haematoma involving subcortical white matter. There is no subarachnoid, subdural, extradural or intraventricular component. The haemtoma has a regular contour without finger-like projections. Tiny further haemorrhage in the left periventricular white matter.

No significant mass effect.

Severe periventricular low attenuation in keeping with small vessel disease.  Moderate generalised cerebral volume loss.

Case Discussion

Left occipital lobar haemorrhage without extension into the subarachnoid space or finger-like projections. Tiny further periventricular haemorrhage. Background changes of severe small vessel disease and moderate atrophy.

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 uses 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 no subarachnoid haemorrhage or finger-like projections from the haematoma. The patient did not possess at least one APOE e4 allele. Therefore they are low 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: Post mortem one year later showed a large acute left sided haemorrhage and old left occipital haematoma.  There is extensive small vessel disease throughout the white matter in the form of lipohyalinosis and arteriolosclerosis.  Immunohistochemistry shows patchy meningeal vascular amyloid.  The haemorrhages are likely related to non-CAA small vessel disease

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Case information

rID: 58533
Published: 22nd Feb 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included
Institution: University of Edinburgh

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