What work‑up and secondary‑prevention plan is recommended for a patient with a right‑frontal lobar intracerebral hemorrhage that is atypical for a hypertensive bleed (e.g., young age, no hypertension)?

Work-up and Secondary Prevention for Atypical Right Frontal Lobar ICH

For a young patient with right frontal lobar ICH without hypertension, you must obtain head CTA with venography to exclude macrovascular causes and cerebral venous thrombosis, followed by MRI with contrast to evaluate for underlying structural lesions and small vessel disease patterns. 1

Initial Vascular Imaging

Perform CT angiography (CTA) of the head plus venography immediately in this clinical scenario, as guideline criteria are met: lobar spontaneous ICH with age <70 years without history of hypertension. 1

• CTA has >90% sensitivity and specificity for detecting intracranial vascular malformations including arteriovenous malformations, aneurysms, and dural arteriovenous fistulas. 1
• Venography (CTV or MRV) is essential to exclude cerebral venous sinus thrombosis, which can present with atypical lobar hemorrhage and requires anticoagulation even in the presence of ICH. 1

If CTA shows any suggestion of a vascular anomaly, proceed to catheter angiography for definitive diagnosis and potential endovascular treatment. 1

MRI Protocol When Stable

Obtain MRI head without and with IV contrast once the patient is medically stable (typically after several days). 1

Key MRI sequences to include:

• T2-weighted gradient echo or susceptibility-weighted imaging (SWI)* to detect microbleeds and cortical superficial siderosis, which suggest cerebral amyloid angiopathy (though less likely given young age) or other small vessel diseases. 1, 2
• Contrast-enhanced T1-weighted sequences to exclude underlying tumor (particularly metastases or primary brain tumors) or other mass lesions. 1
• Diffusion-weighted imaging (DWI) and FLAIR sequences to assess for associated ischemia or white matter disease patterns. 1

Repeat contrast-enhanced MRI at 3-6 months if initial imaging is negative to exclude slowly-growing tumors that may have been obscured by acute hemorrhage. 1

Catheter Angiography Indications

Proceed directly to catheter (DSA) angiography if:

• Non-invasive imaging (CTA/MRA) suggests but does not definitively characterize a vascular malformation. 1
• Spontaneous intraventricular hemorrhage is present without identifiable parenchymal source, as this mandates exclusion of vascular anomaly. 1
• Initial non-invasive vascular imaging is negative but clinical suspicion remains high (young age, no risk factors, atypical location). 1

Differential Diagnosis to Systematically Exclude

Based on right frontal lobar location in a young, non-hypertensive patient, prioritize evaluation for: 2, 3

1. Arteriovenous malformations (most common structural cause in young patients)
2. Cavernous malformations (detected on blood-sensitive MRI sequences)
3. Dural arteriovenous fistulas
4. Aneurysms (particularly if any subarachnoid extension)
5. Cerebral venous thrombosis (can present with lobar hemorrhage)
6. Underlying tumor (primary or metastatic)
7. Drug-related hemorrhage (cocaine, amphetamines, other sympathomimetics) - obtain toxicology screen
8. Coagulopathy or anticoagulant use - check PT/INR, aPTT, platelet count

Secondary Prevention Strategy

If vascular imaging is negative (cryptogenic ICH):

Blood pressure control is the cornerstone of secondary prevention. 1

• Target blood pressure <130/80 mmHg for long-term management, though optimal targets for non-hypertensive patients with cryptogenic ICH are less well-defined. 1
• Even in patients without baseline hypertension, implement lifestyle modifications and consider antihypertensive therapy if BP trends upward during recovery. 1

Antiplatelet therapy considerations:

Avoid routine antiplatelet therapy unless there is a compelling indication for cardiovascular disease prevention. 1

• The RESTART trial showed antiplatelet therapy can be considered in ICH survivors with prior cardiovascular disease, but this applies primarily to patients with known vascular risk factors. 1
• For young patients without cardiovascular disease, the risk-benefit ratio does not favor routine antiplatelet use. 1

If structural lesion identified:

• Arteriovenous malformations: Refer for multidisciplinary evaluation (neurosurgery, interventional neuroradiology) for consideration of resection, embolization, or stereotactic radiosurgery. 1
• Aneurysms: Urgent neurosurgical/endovascular consultation for treatment. 1
• Cavernous malformations: Neurosurgical evaluation; resection considered if accessible location and recurrent hemorrhage. 1
• Tumor: Oncologic management per tumor type. 1

Critical Pitfalls to Avoid

• Do not assume hypertensive etiology in young patients or those without hypertension history, even if hemorrhage location could be consistent with hypertensive bleeding. 1
• Do not skip venography - cerebral venous thrombosis is easily missed on routine CTA and requires specific venous phase imaging. 1
• Do not accept negative initial vascular imaging as definitive in high-risk patients; consider repeat imaging or catheter angiography. 1
• Do not delay contrast-enhanced MRI - underlying masses may be obscured by acute hemorrhage and only become apparent on follow-up imaging. 1