Intracranial Hemorrhage

John R. Hesselink, M.D.

Department of Radiology

University of California

San Diego

Intracranial Hemorrhage

Non-traumatic

Hypertension

Aneurysm

AV Malformation

Other

Other causes: bleeding into tumor, hypocoagulable state,

hemorrhagic infarction and iatrogenic

36%

11%

17%

36%

Intracerebral Hemorrhage

High density mass

Evolution depends on size

Perihematoma edema

Enhancement of perimeter

CT Features

Evolution of

Hematomas

Gomori et al, Diag Imag, 1985

Oxyhemoglobin

Deoxyhemoglobin

Methemoglobin

Intact RBC

Macrophage laden with hemosiderin

RBC Lysis

Hemosiderin

Edema &

Ischemia

Brain Hemorrhage

MR Signal Intensities

Time

High <12 hours

Low 1-3 days

Low

High

3-7 days

7+ days

Low

High

14+ days

14+ days

High 1-14 days

STAGE T1WI

Iso

Iso

High

High

Iso

Iso

Low

Oxy Hgb Hyperacute

Deoxy Hgb in RBC

Hemosiderin

Hemichromes

Edema

Acute

Subacute

Early

Late

Chronic

Rim

Center

HEMOGLOBIN

Met Hgb in RBC

Free Met Hgb

T2/GRE/SWI

History: 56 y/o woman suddenly

became obtunded

186

History: 57 y/o man with left

hemiparesis after GI surgery

781 - 25799008

Dx: Hypodense CT hgb

RBCs 2.97, HGB 9, Hct 26.5

{Page 2}

History: 78 y/o man with headache,

nausea & gait problem times 3 days

318

Dx: Acute temporal lobe

hemorrhage

Gait problem {Page 2}

History: 43 y/o man with sudden

onset of right face & arm weakness

645

{Page 2}

Dx: Hyperacute hemorrhage

& AVM

{Page 3}

S 34-40

Septic Emboli

and Acute

Hemorrhage

History: 44 y/o male with acute

confusion & lethargy

152

Acute confusion & lethargy {Page 2}

Acute confusion {Page 3}

{Page 4}

Dx: Choroid plexus / ependymal AVM -

Ventricular + thalamic hemorrhage

{Page 5}

History: 59 y/o man with head trauma

& occipital hemorrhage 2 months ago

376

Dx: Subacute-chronic

hemorrhage

{Page 2}

History: 38 y.o. woman

with headache and seizures

Dx: Cavernous angioma

with hemorrhage

History: Seizures

{Page 2}

History: 23 y.o. female with

nausea & dizziness

143

Nausea &

dizziness

{Page 2}

6 week follow-up scan

{Page 3}

143

Dx: Cavernous angioma

with hemorrhage

{Page 4}

History: 62 y.o. female who fell down

and became comatose

109

Dx: Hypertensive hemorrhage

Fall & coma {Page 2}

History: 61 y.o. male with sudden

headache leading to coma

106

Dx: Hypertensive hemorrhage

Headache & coma {Page 2}

History: 38 y.o. woman with sudden onset of

headache, followed by mental confusion

149

Dx: Basal ganglia hemorrhage - Angio (-); Drug abuse history

Increasing lethargy -6 hours later {Page 2}

History: 63 y/o woman with altered mental

status & left hemiparesis

169

Dx: Lobar hypertensive hemorrhage

Hemiparesis {Page 2}

Hypertensive Hemorrhage

Hypertensive patient

Patient 60 or more years old

Basal ganglia or thalamic location

Criteria for Diagnosis

Hypertensive Hemorrhage

Common Locations

Basal ganglia

Thalamus

Brain stem

Cerebellum

Cerebral

hemisphere

50%

5%

10%

10%

25%

History: 45 y/o man with confusion

& lethargy since yesterday

293

Confusion & lethargy

{Page 2}

Lateral View

{Page 3}

Anterior View

Dx: AV malformation with

temporal lobe hemorrhage

{Page 4}

Oblique View

History: 15 y/o girl with sudden headache

followed by loss of consciousness

280

{Page 2}

Dx: Right temporal lobe

hemorrhage with

intraventricular extension;

Rt temporal lobe AVM

{Page 3}

Post 200 PVA

Pre EMBO

AV Malformation

Seizure

Neurological deficit

Compression of normal brain

Vascular steal phenomenon

Hemorrhage

40% bleed by age 40

Usually more benign than

aneurysm rupture

Clinical Presentation

History: 34 y/o woman presented

with chronic headaches

207

Dx: Cavernous angioma

{Page 2}

History: 33 y/o man was beat up in jail

399

{Page 2}

{Page 3}

Head trauma

Dx: Cavernous angiomas

{Page 4}

History: 18 y/o woman with blurry

vision left eye for 2 months

583

{Page 2} GRE

ADC

DWI

B0

Dx: Cavernous angioma

{Page 3}

Cavernous Angioma

Honeycomb of epithelial-lined

vascular spaces separated by

fibrous collagenous bands

No intervening neural tissue

Well-defined; hemosiderin

& calcification often present

Slight enhancement

Angiogram usually negative

Dx: Capillary telangiectasia

Capillary Telangiectasia

Capillary Telangiectasia

Abnormal dilated capillaries separated by

normal neural tissue

Usually in the pons

Occult clinically, angiographically & on CT

MR features

Brush-like hyperintensity on FLAIR and T2

Stippled enhancement pattern

Mild hypointensity on GRE

Any hemorrhage suggests a mixed lesion

History: 16 y/o male was an

unrestrained driver in an MVA

438

Dx: Axonal shear injuries

{Page 2}

History: 28 y.o. male had severe

closed-head injury 6 months ago

94

Trauma {Page 2}

{Page 3}

Dx: Multiple hemorrhagic

contusions - 6th

nerve nucleus

{Page 4}

History: 9 y/o boy with prior head trauma

466

Dx: Multiple brain contusions

& shear injuries (DAI)

{Page 2}

History: Newborn girl with seizures

& decreased alertness

250

{Page 2}

Newborn with seizures

{Page 3}

{Page 4}

Dx: Hemorrhagic infarct with thrombosis

of deep venous system, straight sinus

& right transverse sinus

Day 7

{Page 5}

2 cm to right

History: 15 y.o. girl with flu-like

syndrome and increasing lethargy

History: Lethargy {Page 2}

Dx: SSS thrombosis

History: Lethargy

{Page 3}

History: 60 y.o. female with

a right hemiparesis

11

Hemiparesis {Page 2}

Dx: Hemorrhagic

lacunar infarct

{Page 3}

Hemorrhagic Infarction

Occurs during 1st week

Hallmark of embolic infarction and venous infarction

Anticoagulant therapy

Increased density on CT

Hyperintense on T1 MR image

History: 77 y/o woman

with right-sided weakness

733

{Page 2}

Dx: Amyloid angiopathy

{Page 3}

Amyloid Angiopathy

Deposition of eosinophilic material in media

& adventitia of small arteries & arterioles

Fibrinoid degeneration

Microaneurysmal dilatation

Multiple cortical hemorrhage

Associated with aging & Alzheimer's disease

History: 22 y/o man with acute lymphoblastic leukemia

presents with headache & vomiting

586

Dx: Hemorrhages secondary to

thrombocytopenic purpura

{Page 2}

Hypocoagulable

State

History: 58 y.o. veteran

with left arm weakness

Dx: Glioblastoma

{Page 2}

History: 38 y.o. man with new onset seizures

74

Dx: Metastatic melanoma -

Hemorrhagic

{Page 2}

64

History: 67 y.o. male with visual

problems for 2 weeks

Visual problems

{Page 2}

{Page 3}

Dx: Hemorrhage mets -

Thyroid CA {Page 4}

History: 37 y/o man with headaches & decreased vision

541

{Page 2}

Dx: Hemorrhagic Pituitary

adenoma

{Page 3}

Dx: Pituitary apoplexy

History: 24 y/o female

with a visual deficit

554

Epidural & Subdural

Hemorrhage

History: 28 y.o. woman was found

comatose following an MVA

90

Dx: Acute epidural

hematoma with fracture

Trauma {Page 2}

Extracerebral Hemorrhage

Evolve more slowly

Hemosiderin uncommon

Chronic lesions isointense on T1WIs More dilution from CSF

Breakdown of free methemoglobin

Less resorption of fluid component

Key Differences

History: 62 y/o male found down

confused & disoriented

269

Confused

{Page 2}

Dx: Bilateral subacute

subdural hematomas

{Page 3}

History: 75 y.o. man with mental status change

Dx: Acute hemorrhage into

chronic subdural

hematomas

History: Mental status

change {Page 2}

History: One y/o boy fell out of bed & was

having difficulty moving the right arm

292

Trauma {Page 2}

{Page 3}

FLAIR

{Page 4}

T1WI's

Dx: NAT (non-accidental trauma)

- Multiple SDHs of varying

ages & brain contusions

{Page 5} T2W

FLAIR

GRE

Subarachnoid

Hemorrhage

Subarachnoid Hemorrhage

Conventional MR sequences insensitive

FLAIR good for cortical sulci & posterior fossa

Hemorrhage evolves more slowly

Subacute & chronic SAH not visible due to dilution

Pial siderosis with repeated small hemorrhages

History: 57 y/o female with

acute intracranial hemorrhage

373

Dx: SAH - FLAIR

{Page 2}

History: 50 y/o man with atrial fibrillation,

hearing loss & nystagmus

470

Dx: Pial siderosis

(on coumadin x 10 yrs)

{Page 2}