Symptomatic lobar intracerebral haemorrhage preceded by transient focal neurological episodes

We report the case of a symptomatic intracerebral haemorrhage (ICH) in an elderly woman, secondary to cerebral amyloid angiopathy (CAA), and present the relevant imaging. A few months before, our patient experienced multiple, stereotyped, brief episodes of spreading paraesthesias, which were considered to be transient ischaemic attacks (TIAs) and treated with antithrombotic agents. In this case report, we explore CAA, a highly prevalent but under-recognised form of small vessel cerebrovascular disease and common cause of ICH. We then briefly discuss the clinical significance of transient focal neurological episodes in the context of CAA, as potential warning signs of future ICH. An important clinical message is that misdiagnosis of CAA-related focal neurological symptoms as TIAs (and prescribing antithrombotic drugs) could lead to potentially avoidable ICH. We also provide the current evidence base for the acute and secondary prevention treatment of patients with lobar ICH attributed to CAA, and discuss the prognosis.