In a consecutive series of 26 cases of lobar hemorrhage, we found 11 to lie within the occipital lobe, causing pain around the ipsilateral eye and a dense homonymous hemianopia; 7 in the temporal lobe that produced pain in or anterior to the ear, partial hemianopia, and fluent aphasia; 4 in the frontal lobe, with frontal headache and contralateral hemiplegia, mainly of the arm; and 3 in the parietal lobe that presented with anterior temporal headache and hemisensory deficit contralaterally (Ropper and Davis). The smaller hematomas simulate an embolic stroke in the same territory. The occurrence of a progressively worsening headache, vomiting, or drowsiness in conjunction with any one of these syndromes is virtually diagnostic, and, of course, the presence of a lobar hemorrhage is readily corroborated by an unenhanced CT. Of our 26 patients, 14 had normal blood pressure, and in several of the fatal cases there was amyloidosis of the affected vessels; 2 patients were receiving anticoagulants, 2 had an arteriovenous malformation, and 1 had a metastatic tumor. Similarly, in the series of 22 patients with lobar clots reported by Kase and colleagues, 55 percent were normotensive; metastatic tumors, arteriovenous malformations, and blood dyscrasias were found in 14, 9, and 5 percent of the patients, respectively. The role of amyloid angiopathy in lobar hemorrhage in the elderly patient is discussed further on.
For the rapid diagnosis of intracerebral hemorrhage, cerebral imaging occupies the foremost position (see
Fig. 33-24). It is reliable in the detection of hemorrhages that are less than 1.0 cm in diameter. Very small pontine hemorrhages may be overlooked because of the artifact produced by adjacent bone. The spot sign on CT angiography has been mentioned above in relation to hematoma expansion. At the same time, coexisting hydrocephalus, tumor, cerebral swelling, and displacement of the intracranial contents are readily appreciated. MRI is particularly useful for demonstrating brainstem hemorrhages and residual hemorrhages, which remain visible long after they are no longer detectable on the CT (after 4 to 5 weeks). Hemosiderin and iron pigment have characteristic appearances, as described earlier and in Chap. 2.
In general, lumbar puncture is ill advised, for it may precipitate or aggravate an impending shift of central structures and herniation. The white cell count in the peripheral blood may rise transiently to 15,000/mm3, a higher figure than in thrombosis, but it is most often normal. The sedimentation rate may be mildly elevated in some patients. Determination of the INR, partial thromboplastin time, and platelet count is advisable.