A 56-year-old normotensive man had recurrent lobar intracerebral hemorrhages.

Our patient had multiple, bilateral, recurrent, lobar posterior intracerebral hemorrhages. Intracranial hemorrhage is defined as any bleed occurring within the cranial cavity. An intracranial hemorrhage may be epidural, subdural, subarachnoid, parenchymal, or intraventricular. Intracerebral hemorrhage is one of the most deadly stroke subtypes and accounts for 10% to 15% of all strokes in Western countries. Arterial hypertension is the most common cause of nontraumatic intracerebral hemorrhage in adults. Other major causes include intracranial aneurysms, CNS vascular malformations, bleeding diatheses, anticoagulant therapy, thrombolytic therapy, cerebral amyloid angiopathy (CAA), brain tumors, vasculitides, and drug abuse. Hypertensive hemorrhages often involve the putamen, thalamus, subcortical white matter, cerebellum, or pons.

Brain hemorrhages often occur during activity. Headaches are present in half of the patients. Nausea and vomiting are present in over half of the patients. The level of alertness may be variably compromised. Seizures rarely occur at onset of bleeding. Signs of meningeal irritation signs may result if bleeding extends to the subarachnoid space. Fundoscopy may show retinal hemorrhages.

Hematoma location, size, direction of spread, and rate of bleeding play a major role in ultimately determining clinical presentation and outcome. A lobar intracerebral hemorrhage refers to bleeding parenchymatous bleeding involving the subcortical supratentorial white matter and located outside the deep nuclear structures. Frontal lobar hemorrhages often result in contralateral hemiparesis and abulia. Conjugate eye deviation towards the side of the hematoma may occur. Bifrontal headache is frequently reported. Parietal lobe hemorrhages result in contralateral hemisensory loss and neglect of the contralateral visual field. Variable degrees of contralateral homonymous hemianopia, mild hemiparesis, and anosognosia may be present. Dominant temporal lobe hemorrhages result in Wernicke aphasia. Left temporoparietal hematomas result in conduction or global aphasia. Temporal lobe hemorrhages may also result in contralateral visual field defects, or agitated delirium. Occipital lobe hemorrhages are associated with ipsilateral orbital pain and contralateral homonymous hemianopsia.