A 75-year-old man is brought to the emergency department due to problems with vision and right-sided hemisensory loss that started an hour ago. While in the emergency department, his symptoms gradually worsen and he develops a headache. Head CT reveals multiple, small lobar hemorrhages of varying ages in the occipital and parietal areas with a medium-size acute bleed in the left parietooccipital lobe. Two years ago, the patient developed sudden right arm weakness; neuroimaging at that time demonstrated a small left frontal lobe hemorrhage. He has no head trauma and does not use anticoagulants. This patient most likely suffers from which of the following?

Question

A 75-year-old man is brought to the emergency department due to problems with vision and right-sided hemisensory loss that started an hour ago.  While in the emergency department, his symptoms gradually worsen and he develops a headache.  Head CT reveals multiple, small lobar hemorrhages of varying ages in the occipital and parietal areas with a medium-size acute bleed in the left parietooccipital lobe.  Two years ago, the patient developed sudden right arm weakness; neuroimaging at that time demonstrated a small left frontal lobe hemorrhage.  He has no head trauma and does not use anticoagulants.  This patient most likely suffers from which of the following?

Quizplus · Accepted Answer

This elderly patient likely has recurrent lobar hemorrhage due to cerebral amyloid angiopathy. Amyloid angiopathy is a consequence of β-amyloid deposition in the walls of small- to medium-sized cerebral arteries, resulting in vessel wall weakening and predisposition to rupture. The disease is not associated with systemic amyloidoses; rather, the amyloidogenic proteins are usually the same as those seen in Alzheimer disease. Amyloid angiopathy is the most common cause of spontaneous lobar hemorrhage, particularly in adults age >60. Hemorrhage tends to be recurrent and most often involves the occipital and parietal lobes. Occipital lobe hemorrhage is typically associated with homonymous hemianopsia; parietal hemorrhages can cause contralateral hemisensory loss. Frontal lobe hemorrhage is less common but may result in contralateral hemiparesis. (Choice A) Brain arteriovenous malformation is the most common cause of intracranial hemorrhage in children and tends to be a single lesion. This patient's older age and multifocal hemorrhages make the diagnosis less likely. (Choices B and C) Carotid artery atherosclerosis and cardiac embolism may cause acute ischemic stroke, which typically presents with sudden neurologic deficits that are maximal at symptom onset. Embolic stroke can present with multiple infarcts involving the cerebral cortex and has a higher likelihood of spontaneous hemorrhagic transformation. However, hemorrhagic transformation would be rare within hours of symptom onset. In addition, this patient's gradually worsening symptoms are more consistent with hemorrhagic stroke. (Choice E) Charcot-Bouchard aneurysm rupture is usually due to chronic hypertension and typically causes hemorrhage involving deep brain structures (eg, basal ganglia, cerebellar nuclei, thalamus, pons). This patient's recurrent lobar hemorrhages make this less likely. (Choice F) Hypertensive encephalopathy is characterized by progressive headache and nausea/vomiting followed by nonlocalizing neurologic symptoms (eg, confusion). This patient's focal neurologic deficits and evidence of hemorrhage on neuroimaging exclude this diagnosis. (Choice G) Hypoxic encephalopathy occurs from global interruption of the cerebral blood supply (eg, due to cardiac arrest). It most often presents with decreased consciousness (eg, coma, vegetative state) as opposed to focal neurologic deficits with lobar hemorrhage. (Choice H) Saccular aneurysm rupture is typically associated with subarachnoid hemorrhage as opposed to intraparenchymal hematoma. Patients usually have an abrupt onset of severe headache (thunderclap headache), and focal neurologic deficits are less common. On CT, subarachnoid hemorrhage appears as hyperattenuation of the sulci and basal cisterns. Educational objective: Cerebral amyloid angiopathy is the most common cause of spontaneous lobar hemorrhage, particularly in the elderly. The most common sites of hemorrhage include the occipital and parietal lobes. __________ References: Cerebral amyloid angiopathy-related hemorrhages. (http://www.ncbi.nlm.nih.gov/pubmed/18690512)

A 75-Year-Old Man Is Brought to the Emergency Department Due