An 85-year-old woman is brought to the emergency department with headache and right-sided weakness. Family members report that she was in her usual state of health until 2 hours ago. Six months ago, the patient had an intracerebral hemorrhage into the right occipital lobe. Past medical history includes hypertension and type 2 diabetes mellitus. She was treated for locally invasive breast cancer 7 years ago with surgery and chemotherapy.
Her blood pressure is 150/90 mm Hg and pulse is 90/min. Neurologic examination shows right hemiparesis with right facial droop, dysarthria, and right hemisensory loss.
Noncontrast CT of the head reveals a moderate-sized, left frontoparietal lobar hemorrhage with mass effect. MRI of the brain with and without gadolinium shows no enhancement or acute infarction.
Which of the following is the most likely cause of this patient's current condition?

Question

An 85-year-old woman is brought to the emergency department with headache and right-sided weakness.  Family members report that she was in her usual state of health until 2 hours ago.  Six months ago, the patient had an intracerebral hemorrhage into the right occipital lobe.  Past medical history includes hypertension and type 2 diabetes mellitus.  She was treated for locally invasive breast cancer 7 years ago with surgery and chemotherapy.
Her blood pressure is 150/90 mm Hg and pulse is 90/min.  Neurologic examination shows right hemiparesis with right facial droop, dysarthria, and right hemisensory loss.
Noncontrast CT of the head reveals a moderate-sized, left frontoparietal lobar hemorrhage with mass effect.  MRI of the brain with and without gadolinium shows no enhancement or acute infarction.
Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

This patient, who has a history of a right occipital lobe intracerebral hemorrhage (ICH) and now has a left frontoparietal lobar ICH, likely has cerebral amyloid angiopathy (CAA). CAA is the second most common cause of ICH and is due to infiltration of cerebral blood vessels with an abnormal beta-pleated sheet protein (amyloid), which causes the blood vessels to lose their natural elasticity and become more fragile and bleed easily. Most patients are asymptomatic but may present with transient neurologic symptoms (eg, weakness, paresthesias) or, more commonly, symptoms of spontaneous lobar ICH (eg, headache, focal deficits or hemiparesis, seizures, altered mental status). CAA is probable in patients age >75 with multiple lobar (ie, cortical and subcortical white matter) hemorrhages on brain imaging. Hemorrhage usually spares the ventricles and deep brain structures (eg, putamen, thalamus, pons). Postmortem examination confirms the diagnosis. Treatment is similar to other cases of ICH. The overall outcome of patients with CAA is slightly better than in those with hypertensive hemorrhage, although the risk of recurrence and rate of complications are higher. (Choice A) ICH due to an arteriovenous malformation usually occurs between age 10-40. Hemorrhage also commonly extends into the ventricles or subarachnoid space and is not limited to a lobar area. (Choice C) Hypertensive hemorrhages are the most common cause of ICH. However, they occur most frequently in the basal ganglia (putamen) followed by the thalamus, pons, and cerebellum (unlike the lobar ICHs seen with CAA). This patient's history of recurrent lobar ICH and her only moderately elevated blood pressure on presentation make CAA more likely than hypertensive hemorrhage. (Choice D) Most patients with central nervous system metastases have slow onset of symptoms (eg, headache, focal deficits, seizures) but can present acutely due to hemorrhage into the tumor. Metastatic breast cancer can cause lobar ICH. However, this patient's brain MRI did not have the enhancement usually seen in neoplasms causing ICH. (Choice E) A ruptured berry aneurysm usually presents in patients age 40-60 with the sudden onset of headache ("thunderclap"), confusion, fever, and nuchal rigidity. A CT scan reveals bleeding within the subarachnoid space as opposed to lobar or intraparenchymal bleeding. Educational objective: Amyloid angiopathy is the second most common cause of intracerebral hemorrhage, especially in patients age >75. The location of the hemorrhage is typically lobar. The risk of recurrence is high. __________ References: Symptomatic lobar intracerebral haemorrhage preceded by transient focal neurological episodes. (http://www.ncbi.nlm.nih.gov/pubmed/23661651)

An 85-Year-Old Woman Is Brought to the Emergency Department with Headache