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Cerebral Hemorrhage

Last Updated: March 27, 2020

Open Table of Contents: Cerebral Hemorrhage

Figure 1: There is a moderate sized lesion in the right thalamus with T1 isointense signal (top row left), heterogeneous isointense and hyperintense signal on FLAIR (top row right) with associated susceptibility artifact centrally on SWI (middle row left). Note that there is a mild amount of reduced diffusivity which in this case is likely due to the susceptibility artifact from the hemorrhage on DWI/ADC (middle row right, bottom row left). Enhancement may be present in the periphery as in this case (bottom row right), particularly in the subacute stage. Notice that the age of the blood products is not clear by signal intensities. Often the signal characteristics are heterogeneous, as is seen in this case, making accurate staging difficult and potentially inaccurate.

Description

  • Many causes including hypertension, infarction, underlying malignancy, AVM, cerebral amyloid angiopathy, drug abuse, etc.
  • Highly-vascularized, malignant primary brain tumors tend to bleed spontaneously and should always be included in the differential diagnosis of non-traumatic intracerebral hemorrhage.
  • Up to 10% of patients with brain tumors may experience a diagnostic delay if CT is the only imaging modality

Pathology

  • Variable depending on the underlying etiology

Clinical Features

  • Symptoms
    • Headache, sensorimotor deficits, altered mental status, herniation syndromes
  • Age and Gender

    • Variable depending on the underlying etiology
  • Prognosis

    • Related to location and size
    • Roughly 25% of patients die within the first 48 hours

Imaging

  • General
    • Round, oval or irregular
    • Location varies with etiology
      • Hypertension: striatocapsular > thalamus > pons and cerebellum
      • Thrombosis: follows arterial or venous territories
      • Amyloid: peripheral/lobar
      • Malformations and malignancies: any location
  • Modality specific

    • CT
      • Hyperdense hematoma with surrounding hypodense edema in the acute setting
      • Hematoma becomes less dense with time
    • CTA/CTV

      • Only helpful when suspected thrombosis
    • MR

      • Signal characteristics correspond to the age of the blood products
      • Hyperacute (<24 hours)
        • T1 isointense, T2 hyperintense
        • Intracellular oxyhemoglobin
      • Acute (24 hours – 3 days)

        • T1 isointense, T2 hypointense
        • Intracellular deoxyhemoglobin
      • Early Subacute (3 days - 7 days)

        • T1 hyperintense, T2 hypointense
        • Intracellular methemoglobin
      • Late Subacute (7 days – 3 weeks)

        • T1 hyperintense, T2 hyperintense
        • Extracellular methemoglobin
      • Chronic (> 3 weeks)

        • T1 and T2 hypointense
        • Extracellular hemosiderin
      • T2*

        • Often hypointense signal, particularly with hemosiderin deposition
      • Contrast

        • May demonstrate enhancement if underlying malignancy or vascular malformation
        • Small amount of reactive enhancement may also be present around a subacute hematoma
      • MRA/MRV

        • Helpful to look for thrombosis
    • Conventional Angiogram

      • Helpful to look for thrombosis or underlying vascular malformation
    • Dual-Energy CT

      • May prove useful for rapid identification of the underlying etiology
      • Many recent studies have demonstrated the utility of dual-energy CT for detecting underlying vascular malformations and malignancy in the setting of an intracranial hemorrhage
  • Imaging Recommendations

    • Start with NECT
      • If etiology is clear from history, no need for further imaging
      • If unclear, recommend CTA to evaluate for underlying vascular malformation or thrombosis
    • MR with contrast and T2* sequence

      • If CT negative or etiology unclear
      • If a vascular etiology is suspected, recommend CTA, MRA, or MRV
    • Recommend followup MR or DSA if etiology remains unclear, since a recent hematoma may mask underlying tumor or vascular lesion
    • Dual-energy CT may be a useful tool in detecting underlying tumors in patients with an ICH of unknown origin
  • Mimic

    • On initial imaging, can be difficult to distinguish bland hematoma from vascular malformations or hemorrhagic neoplasms. If initial MRI or angiography isn’t helpful in delineating the underlying etiology, followup MR or conventional angiography may be necessary. More recent studies suggest that initial evaluation with dual energy or spectral CT may help identify the underlying etiology.

For more information, please see the corresponding chapter in Radiopaedia.

Contributor: Sean Dodson, MD

DOI: https://doi.org/10.18791/nsatlas.v1.03.02.10

References

Bell D, et al. How well do radiologists diagnose intracerebral tumour histology on CT? Findings from a prospective multicentre study. Br J Neurosurg. 2002; 16:573–577.

Kim SJ, et al. Dual-energy CT in the evaluation of intracerebral hemorrhage of unknown origin: differentiation between tumor bleeding and pure hemorrhage. AJNR Am J Neuroradiol. 2012; 33:865–872.

Postma AA, et al. Dual-Energy CT: What the Neuroradiologist Should Know. Curr Radiol Rep. 2015; 3(5): 16.

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