Central sulcus hemorrhage is a rare imaging finding that can be related to cerebral amyloidosis in a normotensive non-traumatic elderly patient and present as an isolated finding or in association with other areas of involvement. We report a case presenting with an isolated central sulcus hemorrhage on computed tomography. Further imaging work-up excluded other potential causes of peripheral hemorrhages and established a putative diagnosis of cerebral amyloidosis.
Intracranial hemorrhage could be located within the deep white matter, cortical/subcortical, subarachnoid, subdural, epidural, or intraventricular locations. The most common etiologies for intracranial bleeding include trauma and hypertension. Cerebral amyloid angiopathy (CAA) is a common cause of non-traumatic peripheral intracranial hemorrhage in a normotensive patient, and may present as an isolated cortical or subcortical hemorrhage. Imaging evaluation supplements the nonspecific clinical features and helps to characterize the etiology of the hemorrhage and associated complications. Prompt diagnosis of acute as well as chronic presentations of cerebral amyloidosis is important and would result in appropriate management and care.
An 84-year-old woman with history of breast cancer presents to the emergency department with intermittent numbness and paresthesias of the right upper and lower extremities for two days. There is no associated headache, vertigo, or vision problem during the course of illness. There is no history of trauma. There were no constitutional symptoms or chest pain and palpitations. Patient denied any history of unusual bruising, bleeding, or coagulation problems. There is no relevant family history. Vitals signs were stable. Neurological examination was unremarkable without any sensory or motor deficits. The laboratory values were normal.
Unenhanced computed tomographic (CT) head scan demonstrated increased attenuation along the left cerebral convexity consistent with isolated central sulcus hemorrhage without any mass effect or midline shift (Figure
Unenhanced CT images of the brain. Axial and coronal CT images ((a) and (b)) of the brain in an 84-year-old normotensive female without history of trauma demonstrate a linear area of increased attenuation within the left frontal convexity, consistent with an isolated central sulcus hemorrhage.
MR images of the brain. Axial FLAIR image (image a) of the index case confirms the finding of left central sulcus hemorrhage seen on the CT scan. Coronal gradient echo images (image b) demonstrate corresponding loss of signal within the left central sulcus. Coronal gradient echo images (images c, d) demonstrate signal loss within other adjacent cortical and subcortical areas consistent with hemorrhages and siderosis. Imaging findings and clinical presentation support the working diagnosis of cerebral amyloid angiopathy.
Associated findings. Unenhanced CT and MR FLAIR images of the brain demonstrate non-specific white matter related changes that can be associated with peripheral hemorrhages in cerebral amyloidosis.
Other similar cases with findings of isolated central sulcus hemorrhage and a diagnosis of cerebral amyloidosis based on Boston criteria are illustrated in Figures
Second case of isolated central sulcus hemorrhage. MR images in a 67-year-old female with history of nasal cavity lymphoma presenting with right sided weakness. There is no history of trauma, hypertension, or bleeding diathesis. Flair MRI (image (a)) demonstrates isolated increased signal within the left central sulcus with corresponding loss of signal on gradient echo (image (b)) consistent with isolated central sulcus hemorrhage. Nonspecific white matter changes are seen on the FLAIR sequence (image (c)). MR angiogram did not demonstrate any aneurysms or vascular malformations. A probable diagnosis of cerebral amyloidosis was made based on the Boston criteria. Follow up MR images demonstrated interval resolution of the acute hemorrhage with chronic cortical and subcortical changes on the gradient echo sequences (image (d)).
Third case of isolated central sulcus hemorrhage. Gradient echo MR images in a 50-year-old female with history of renal transplant and presenting with left leg weakness demonstrated signal loss within the left central sulcus consistent with an isolated hemorrhage. Associated nonspecific white matter changes were also seen. Angiographic work up was without any evidence of aneurysms or vascular malformations. Although the age of the patient and absence of other areas of chronic hemorrhage on MR imaging make this an atypical presentation, findings of an isolated central sulcus hemorrhage in a normotensive patient without other etiologies accounting for that hemorrhage would suggest a possible diagnosis of CAA.
Various etiologies summarized in Table
Etiologies that can present with cortical, subcortical, or sulcal hemorrhage [
(i) Amyloid angiopathy (cortical/subcortical in location, may be associated with subarachnoid and subdural hemorrhages) | |
(ii) Aneurysm rupture (subarachnoid and cisternal) | |
(iii) Arterial dissection (subarachnoid hemorrhage, majority involve the posterior circulation) | |
(iv) Bleeding diathesis (may show fluid-blood levels, associated with thrombocytopenia or abnormal prothrombin time) | |
(v) Drug abuse (intraparenchymal or subarachnoid hemorrhage) | |
(vi) Hypertension (central, involving the thalamus and basal ganglia) | |
(vii) Malignancy (subcortical, associated edema and mass effect) | |
(viii) Posterior reversible encephalopathy syndrome or PRES (focal intracerebral and subarachnoid hemorrhage with characteristic signal changes) | |
(ix) Trauma (predilection for inferior frontal and temporal lobes) | |
(x) Vascular malformations (subarachnoid or cortical hemorrhages, better characterized on CT or MR angiograms) | |
(xi) Vasculitis (intraparenchymal and associated with multiple areas of subcortical infarctions) | |
(xii) Venous thrombosis (subcortical) |
Cerebral amyloidosis is one of the etiologies for spontaneous non-traumatic cortical or subcortical bleed in a normotensive patient. Amyloid deposition in the brain occurs within various pathologies such as Alzheimer’s dementia, Creutzfeld Jacobs’s disease, spongiform encephalopathies, and postradiation necrosis or can be rarely hereditary [
Cerebral amyloidosis commonly presents as peripheral cortical or subcortical hemorrhage but other rare and nonspecific patterns have been described in Table
Imaging presentations of cerebral amyloidosis [
(i) Intracranial hemorrhage: | |
(a) Acute and chronic cortical, subcortical, and rarely intraventricular | |
(b) Spares the deep white matter, thalamus, and basal ganglia | |
(c) Central sulcus hemorrhage | |
(d) Characteristically multiple, bilateral, peripheral, and lobulated hemorrhages with coexisting old hemorrhages support the diagnosis | |
(ii) Leukoencephalopathy | |
(iii) Atrophy and cerebral volume loss | |
(iv) Vascular luminal narrowing and ischemia | |
(v) Amyloidoma simulating a mass |
Imaging modalities for evaluation of peripheral intracranial hemorrhage.
(i) Non-contrast CT: initial test of choice | |
(ii) MRI: | |
(a) FLAIR—acute or subacute hemorrhage (non-specific) | |
(b) GRE or SWI—decreased signal and blooming in areas of prior hemorrhage | |
(iii) CT and MR angiograms: diagnosis and characterization of aneurysms, AVM, and vasculitits | |
(iv) Angiography: limited value, invasive procedure |
Imaging plays an important role in recognition of typical patterns of various types of intracranial hemorrhage. It complements the clinical diagnosis and guides further management. Cerebral amyloidosis is a diagnosis of exclusion with varied clinical and imaging presentations. The typical imaging findings include a peripheral cortical or subcortical hemorrhage with other areas of chronic hemorrhage in an elderly, normotensive, and non-traumatic setting. As presented in our cases, an isolated central sulcus hemorrhage is rare and is reported to be most frequently associated with cerebral amyloidosis. Although histopathological diagnosis is seldom pursued, an isolated central sulcus hemorrhage may suggest a putative diagnosis of cerebral amyloid angiopathy, especially when further imaging and clinical presentation exclude alternative diagnoses.
Arteriovenous malformation
Cerebral amyloid angiopathy
Computed tomography
Fluid attenuation inversion recovery
Gradient echo
Magnetic resonance imaging
Posterior reversible encephalopathy syndrome
Susceptibility weighted imaging.