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Topic 1128 Version 45.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 37/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate GRAPHICS Lobar hemorrhage in cerebral amyloid angiopathy Acute superficial lobar hemorrhage in the left frontal lobe seen on computed tomography scan in a patient with cerebral amyloid angiopathy (A). Flair magnetic resonance image performed one week later shows the high signal intensity of subacute hemorrhage with surrounding edema extending into the subcortical white matter (B). Hemorrhage (now low signal intensity consistent with hemosiderin) and edema are mostly resolved on a three-month follow-up study (C). Courtesy of Eric D Schwartz, MD. Graphic 50480 Version 4.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 38/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Characteristic features and initial diagnostic imaging for common underlying causes of spontaneous isolated convexity subarachnoid hemorrhage Suspected Choice of initial diagnostic Characteristic feature(s) etiology imaging test(s) Age >60 years CAA MRI brain with T2*-weighted SWI or GRE sequences Baseline cognitive impairment Recurrent thunderclap headache (>2 RCVS CTA or MRA of head within 1 week) MRI brain Exposure to vasoactive substance Risk factor for venous thrombosis* CVT CTV or MRV of head Head CT features suggestive of venous thrombosis (eg, hyperdense venous sinus; venous infarction) MRI brain New heart murmur Mycotic aneurysm MRI brain with contrast or cerebral DSA Systemic/cutaneous evidence of embolism Clinical history of active cancer Brain tumor MRI brain with contrast Clinical history of new persistent headaches Head CT features suggestive of tumor (eg, vasogenic edema) Headache prior to neurologic deficits Intracranial dissection CTA of head or cerebral DSA Clinical history of connective tissue disorder Head CT features suggestive of AVM AVM Cerebral DSA (calcification or hypodense flow voids adjacent to SAH) History of minor/occult trauma may be Occult trauma MRI brain elicited Evidence of extracranial bleeding or systemic injuries Clinical history of new persistent headaches Vasculitis MRI brain with contrast Cerebral DSA Progressive cognitive or other neurologic impairments Brain and meningeal biopsy https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 39/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Patients with spontaneous isolated convexity SAH present with bleeding restricted to the surface of the cerebral hemispheres. The suspected underlying cause of convexity SAH may be identified by initial diagnostic imaging test. Additional imaging and/or other testing may be warranted if initial imaging is nondiagnostic. Refer to specific UpToDate topics for additional information on the diagnostic evaluation of conditions that may present with convexity SAH. SAH: subarachnoid hemorrhage; CAA: cerebral amyloid angiopathy; MRI: magnetic resonance imaging; SWI: susceptibility-weighted imaging; GRE: gradient recall echo imaging; RCVS: reversible cerebral vasoconstriction syndrome; CTA: computed tomographic angiography; MRA: magnetic resonance angiography; CT: computed tomography; CVT: cerebral venous thrombosis; CTV: computed tomography venography; MRV: magnetic resonance venography; DSA: digital subtraction angiography; AVM: arteriovenous malformation. Refer to UpToDate topic on the causes of venous thrombosis. Graphic 140108 Version 2.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 40/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Old hemorrhages on gradient echo MRI Comparison of CT scan (A), T2- weighted MRI (B), and gradient echo MRI (C) demonstrates the utility of the last for detecting old hemorrhages consistent with cerebral amyloid angiopathy. In addition to the the left frontoparietal hemorrhage seen on all studies (arrowheads), the gradient- echo sequence demonstrates multiple areas of decreased signal in gray- white regions (arrows) consistent with chronic hemorrhage. CT: computed tomography; MRI: magnetic resonance imaging. Reproduced with permission from Greenberg SM, Finklestein SP, Schaefer PW. Petechial hemorrhages accompanying lobar hemorrhage: detection by gradient-echo MRI. Neurology 1996; 46:1751. Graphic 81579 Version 12.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 41/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Acute and subacute lobar hemorrhage Noncontrast head CT shows acute right parietal ICH (A). T2* susceptibility-weighted sequence on MRI performed one day later shows an acute ICH in the right frontal and parietal hemisphere (B) as well as a subacute hemorrhage in the left occipital lobe (thick arrow) and chronic ICH in right inferior parietal lobule (C; arrow). In addition, multiple microbleeds at cerebral corticomedullary junctions (B, C) are consistent with cerebral amyloid angiopathy. CT: computed tomography; ICH: intracerebral hemorrhage; MRI: magnetic resonance imaging. Courtesy of Glenn A Tung, MD, FACR. Graphic 132283 Version 1.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 42/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Distinctive distribution of cerebral microbleeds (A-C) CMBs on T2*-weighted gradient echo MRI sequences suggestive of deep penetrating (hypertensive) vasculopathy. CMBs predominate in bilateral thalami (A), brainstem (B), and dentate nucleus of cerebellum (C). (D-F) CMBs on T2*-weighted gradient echo MRI sequences suggestive of cerebral amyloid angiopathy. CMBs predominate in cerebral hemispheres (D, E). Associated findings include lobar hemorrhage (D; arrow and thick arrow) and superficial siderosis (F; circles). CMB: cerebral microbleeds; MRI: magnetic resonance imaging. Courtesy of Glenn A Tung, MD, FACR. https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 43/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Graphic 132282 Version 1.0 https://www.uptodate.com/contents/cerebral-amyloid-angiopathy/print 44/61 7/5/23, 12:19 PM Cerebral amyloid angiopathy - UpToDate Various radiologic patterns of subarachnoid hemorrhage on noncontrast compu tomography (CT) of the head (A) Obvious large SAH: hyperdense blood in all the basal cisterns, with some dilatation of the temporal horn the lateral ventricles, suggesting early hydrocephalus. (B) More subtle, smaller SAH: small hyperdense collection of blood in the basal cistern adjacent to the left p and suprasellar cistern (short solid arrow). (C) Perimesencephalic SAH: the long solid arrows indicate a perimesencephalic (sometimes called a pretrun SAH. These hemorrhages represent approximately 10% of nontraumatic SAHs. They are thought to be caused venous bleeding, will have a negative CTA result, and usually have an excellent outcome. However, the radiographic pattern is also observed with posterior circulation aneurysms, so all of these patients require neurosurgical consultation and vascular imaging. (D) Convexal SAH: the arrowheads indicate a high convexal SAH. This pattern is observed in two groups of