A 74-year-old woman with a history of hypertension and Alzheimer disease presented to our emergency department with sudden-onset headache associated with left-sided hemiparesis, dysarthria, and decreased consciousness. There was no coagulopathy or history of anticoagulation use. The patient's condition rapidly deteriorated, and she required intubation. Neuroimaging was performed approximately 2 hours after ictus, including noncontrast computed tomography (CT), CT angiography, and postcontrast CT studies (Figure 1). The noncontrast CT revealed a 6.6 × 4.5 × 7.5-cm lobar frontoparietal intracerebral hemorrhage (ICH) with associated subdural hematoma causing subfalcine, uncal, and transtentorial herniation. The CT angiography demonstrated 2 “Spot Signs” with evidence of active extravasation on postcontrast CT scans. No underlying secondary vascular cause for ICH was demonstrated. An urgent neurosurgical consultation was obtained, and the patient underwent craniotomy and hematoma evacuation. Samples of the anterior hematoma and hematoma wall were sent to the laboratory for pathological analysis. Postoperatively, the patient was transferred to the intensive care unit and remained hemodynamically stable. Nine months after the event, the patient remained in the hospital awaiting placement in long-term care and was left with severe disability (with a modified Rankin scale of 5).
Figure 1. Computed tomography (CT) studies of a 74-year-old woman at admission to our emergency department: (A) noncontrast CT, (B) CT angiography with presence of 2 Spot Signs (arrows), and (C) postcontrast CT demonstrating both Spot Signs associated active extravasation (arrows).
Figure 2. A, Congo red stain (original magnification ×20) showing amyloid angiopathy affecting small- to medium-caliber vessels. B, Elastic trichrome stain (original magnification ×10) demonstrating an arterial dissection with red blood cells within the true vessel lumen (L) and neolumen (N), the latter being within the vessel wall beneath the black-stained internal elastic lamina (arrow).
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