Presentation
Sudden onset headache and right sided weakness. No history of hypertension.
Patient Data
Large haemorhage in the posterior left temporal lobe with surrounding edema. No intraventricular extension.
The MRI findings are consistent with a large, left temporal lobar haemorhage. No AVM was demonstrated on the MRA (not shown).
3 month follow up scan
A 6.2 x 5.0 x 3.6 cm irregularly peripherally enhancing mass in the left temporal lobe is associated with moderate surrounding edema, with moderate mass effect. The sulci are effaced, with right-sided midline shift of 14 mm, and distortion of the left lateral ventricle. The left temporal horn is moderately prominent, appearing trapped. Some T1 hyperintensity is present together with patchy susceptibility in keeping with blood products. Heterogeneous diffusion restriction.
Conclusion: Solitary intra-axial tumor in the left temporal lobe has overall MRI findings most in keeping with a glioblastoma.
Case Discussion
This patient was not known to have hypertension or any history of a previous cerebral vascular event.
The haemorhage is not in a typical location to be classified as a 'hypertensive bleed', thus we label it as a "lobar bleed".
The patient has no other radiological evidence of microvascular disease. With the eye of faith there is possibly some faint enhancement along the left mesial temporal lobe, but it is hard to appreciate with so much high T1 signal secondary to the bleed.
Teaching point: have a high index of suspicion for a secondary cause of a bleed when the clinical context and anatomical location do not match.
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