Intracranial Hemorrhage I’m from the Government … … and I ... · 1 Intracranial Hemorrhage James G. Smirniotopoulos, M.D. Uniformed Services University Bethesda, MD Smirniotopoulos

1

Intracranial HemorrhageIntracranial HemorrhageJames G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.

Uniformed Services UniversityUniformed Services UniversityBethesda, MDBethesda, MD

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

DisclosuresDisclosures

No financial disclosures nor conflict of No financial disclosures nor conflict of interest to reportinterest to report

I’m from the Government …

… and I here to help!


Causes of HemorrhageCauses of Hemorrhage

TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations


Location of HemorrhageLocation of Hemorrhage

Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid


What is Hemorrhage?What is Hemorrhage?

ExtravasationExtravasation of of RBCsRBCs–– Can be microscopic Can be microscopic …… microbleedsmicrobleeds??

PunctatePunctate or or PetechialPetechial–– Cortical Contusion, Shearing InjuryCortical Contusion, Shearing Injury–– Reperfusion Injury/Hemorrhagic InfarctionReperfusion Injury/Hemorrhagic Infarction

CoalescentCoalescent–– Venous InfarctionVenous Infarction

Confluent HematomaConfluent HematomaSpace or Membrane LimitedSpace or Membrane Limited–– EDH, SDH, SAH, IntraventricularEDH, SDH, SAH, Intraventricular


Appearance of HemorrhageAppearance of Hemorrhage

2


Whole Blood = Cells + PlasmaWhole Blood = Cells + Plasma

= +

RBC’s

~ 35-45%

Serum

~ 55-65%35-45

Hu

60-90 Hu

0-10 Hu

=


Whole Blood = Cells + PlasmaWhole Blood = Cells + Plasma

= +

RBC’s

~ 35-45%

Serum

~ 55-65%35-45

Hu

60-90 Hu

0-10 Hu

=


MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin IsoIso IsoIsoDeDe--oxy Hgboxy Hgb IsoIso (1(1--3hr)3hr) LowLow (2hr)(2hr)

MetMet--Hgb (in cells)Hgb (in cells) HiHi (3(3--14hr)14hr) LowLow

MetMet--Hgb (in soln.) Hgb (in soln.) HiHi HiHi (hrs(hrs--wks)wks)

HemichromesHemichromes LowLow LowLowHemosiderinHemosiderin LowLow LowerLower

Dead RBCs and Thrombolysis


MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin II IIDeDe--oxy Hgboxy Hgb II (1(1--3hr)3hr) DD (2hr)(2hr)

MetMet--Hgb (in cells)Hgb (in cells) BB (3(3--14hr)14hr) DD

MetMet--Hgb (in soln.) Hgb (in soln.) BB BB (hrs(hrs--wks)wks)

HemichromesHemichromes DD DDHemosiderinHemosiderin DD DD

II * ID * BD * BB * DD


Intracranial HemorrhageIntracranial Hemorrhage

TraumaticTraumatic–– EpiduralEpidural–– SubduralSubdural–– SubarachnoidSubarachnoid–– ParenchymaParenchyma

AneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations


NonNon--Penetrating BulletPenetrating Bullet

3






IED: Penetrating InjuryIED: Penetrating Injury

Intracranial air, blood and metal fragments along wound track.


Epidural HematomaEpidural Hematoma

Usually acute clinical presentationUsually acute clinical presentationYoung patients, usually < 40Young patients, usually < 40–– Dura firmly fixed in older pts.Dura firmly fixed in older pts.

Usually unilateralUsually unilateralUsually associated with Skull Usually associated with Skull FxFx


Epidural SpaceEpidural Space

•Scalp & Skull

•Dura & Arachnoid

•Pia and Brain

•Ventricle and CSFSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008

EPIDURAL HEMATOMAEPIDURAL HEMATOMATrauma Trauma --> fracture & concussion> fracture & concussionTearing/stripping of both layers Tearing/stripping of both layers

from inner tablefrom inner tableLaceration of outer periosteal Laceration of outer periosteal

layerlayerLaceration of meningeal vesselsLaceration of meningeal vesselsInner (meningeal dura) intactInner (meningeal dura) intactBlood between naked bone and Blood between naked bone and

duraduraNORMAL arterial pressure NORMAL arterial pressure

continues to dissect continues to dissect periosteumperiosteum from bonefrom bone

4




2 y.o. with dilated pupil2 y.o. with dilated pupil

Midline Herniation: Subfalcial and Downward Transtentorial




Progressive EDHProgressive EDH

8 PM10 AM


Subdural HematomaSubdural Hematoma

Acute to Subacute to Chronic PresentationAcute to Subacute to Chronic PresentationMay present at All agesMay present at All ages–– isolated SDH in infants and the elderlyisolated SDH in infants and the elderly

May be bilateralMay be bilateralNo particular association with fractureNo particular association with fracture



•Scalp & Skull

•Dura

•Arachnoid

•Pia and Brain

•Ventricle and CSF

5


Bridging VeinsBridging Veins



Complex Subdural Hematoma:Complex Subdural Hematoma:AdultAdult

1cm pineal shift, 3cm Right-to-Left shift and SubfalcialHerniation Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

SDH: SDH: SubfalcialSubfalcial HerniationHerniation


Subdural Hematoma StagesSubdural Hematoma Stages

Acute Subacute Chronic< 3 days 3d – 2 wks > 2 wks

Normal Brain Density

⇑

⇓

Hyperdense

Isodense to Brain

Hypodense


Chronic Interhemispheric SubduralChronic Interhemispheric Subdural

6


Interhemispheric SubduralInterhemispheric Subdural



Falx is too thick!


Subarachnoid HemorrhageSubarachnoid Hemorrhage

Zig-Zag into SulciSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Subdural = Epi Subdural = Epi -- ArachnoidArachnoidSup Sag Sinus


Arachnoid MembraneArachnoid Membrane

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy of Alice B. Smith, UCSF

Massive ContusionsMassive Contusions

7


ContreContre--Coup ContusionCoup Contusion






ContusionContusion


ContusionContusion


ContusionContusion

8


Cranial nerves 2-12 intact … but the patient smells badly, not bad, but badly … Anosmia

ContusionContusion


Rough Anterior Skull BaseRough Anterior Skull Base


••Crowns of GyriCrowns of Gyri

••Linear or flame shapeLinear or flame shape

••NOT in depths of SulciNOT in depths of Sulci

Cerebral Cortical ContusionCerebral Cortical Contusion


Shearing Injury (DWI, DAI)Shearing Injury (DWI, DAI)

High velocity MVAHigh velocity MVAShaking injury in infantsShaking injury in infantsHigh frequency/steep impulse impactHigh frequency/steep impulse impact–– Blast InjuriesBlast Injuries–– High velocity bullets and fragmentsHigh velocity bullets and fragments

Small (< 15mm) and Deep (subcortical)Small (< 15mm) and Deep (subcortical)May cause significant May cause significant SxSx –– ComaComaMay produce subtle (executive functioning)May produce subtle (executive functioning)


Coma: Lesions and LocationsComa: Lesions and Locations

Subcortical Subcortical –– many neededmany neededWhite Matter White Matter –– many neededmany neededThalamus Thalamus –– few neededfew neededReticular Activating SystemReticular Activating System–– Dorsal BrainstemDorsal Brainstem–– Only one neededOnly one needed

Shearing Lesions are small (<15mm) and deep (subcortical, WM, Corpus callosum, Thalamus, Brain stem


FindingsFindings

No Midline shiftNo Midline shiftNo explanation for GCS of 6No explanation for GCS of 6Small hemorrhage left occipital hornSmall hemorrhage left occipital horn–– Torn subependymal veins?Torn subependymal veins?–– Shearing Injury?Shearing Injury?

9


26 26 y.oy.o. man in Coma. man in Coma

CT Scan MR Scan w/”blood sensitive” technique

Deep Lesions … including thalamus … “shearing injury”

… causing coma


Corpus CallosumCorpus Callosum

T2W SWI

Deep Lesions … including thalamus … “shearing injury”

… causing coma


Corpus CallosumCorpus Callosum

Dense, compact, white matter, bundles of axons


Corpus Callosum Corpus Callosum --> Ventricle> Ventricle


Corpus Callosum and BGCorpus Callosum and BG


Unconscious Patient Unconscious Patient -- CTCT

Thanks to Pam Schaefer

10



Diffuse Axonal Injury Diffuse Axonal Injury -- FLAIRFLAIRDeep Lesions … including

thalamus … corpus callosum “shearing injury”


Diffuse Axonal Injury Diffuse Axonal Injury -- SWISWI



Dorsolateral BrainstemDorsolateral Brainstem


30 y.o. man after motor cycle crash with facial 30 y.o. man after motor cycle crash with facial swelling and facial fractures. Acute alteration in swelling and facial fractures. Acute alteration in

level of awareness.level of awareness.

No sulci, no cisterns, low-attenuation both temporal lobes, brainstem (mid-brain) hyperattenuating lesion.


Diffuse cerebral swellingDiffuse cerebral swelling

Anoxic DamageAnoxic DamageLoss of AutoregulationLoss of Autoregulation““CommotioCommotio CerebriCerebri””Secondary herniationSecondary herniation–– DuretDuret HemorrhageHemorrhage


DuretDuret HemorrhagesHemorrhages

Downward displaced Downward displaced brainstembrainstemKinks and compresses Kinks and compresses perforatorsperforatorsHemorrhagic InfarctionHemorrhagic Infarction

11



TraumaticTraumaticAneurysmsAneurysms–– SaccularSaccular, , FusiformFusiform, , MycoticMycotic–– Subarachnoid hemorrhage, Subarachnoid hemorrhage, SiderosisSiderosisNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations


1980 2002


Worst HA: NonWorst HA: Non--Contrast CTContrast CT




Subarachnoid ClotsSubarachnoid Clots



LP more sensitive than CTLP more sensitive than CTTrauma is most common cause for RBCTrauma is most common cause for RBC’’S in CSFS in CSF–– Not seen as easily or as often on CTNot seen as easily or as often on CT

SAH on CTSAH on CT–– Blood clotBlood clot–– Usually Aneurysm / AVMUsually Aneurysm / AVM–– Uncommon cause: neoplasmUncommon cause: neoplasm–– Uncommon cause: spinal diseaseUncommon cause: spinal disease

MorbidityMorbidity–– VasospasmVasospasm–– Mass Effect (parenchymal hematoma)Mass Effect (parenchymal hematoma)–– HydrocephalusHydrocephalus

12


Subarachnoid Space: VasospasmSubarachnoid Space: VasospasmThe RBC’s release … ‘Evil Humors’


Aneurysm and RuptureAneurysm and Rupture

SPASM SPASM -- InfarctionInfarction

HEMATOMA HEMATOMA -- Herniation, etc.Herniation, etc.

ReRe--BLEEDINGBLEEDING

HYDROCEPHALUSHYDROCEPHALUS



ANGIOGRAPHY ANGIOGRAPHY –– MRA & CTA:MRA & CTA:––Location of AneurysmLocation of Aneurysm––Multiple (25% are)Multiple (25% are)––Visualize "NeckVisualize "Neck““––Spasm ?Spasm ?––If (If (--) REPEAT in 2) REPEAT in 2--3 wks.3 wks.



LOCATION of ANEURYSMLOCATION of ANEURYSM––8080--85% Anterior Circulation85% Anterior Circulation––1515--20% Posterior/Vertebral20% Posterior/Vertebral


ACOMM ACOMM AnuerysmAnuerysm


AneurysmAneurysm

Round (Round (‘‘berryberry’’) shape) shapeVessel bifurcationVessel bifurcation–– natural weaknessnatural weakness–– exploited by high BPexploited by high BP

Common sites:Common sites:–– ACA <ACA <--> ACOMM> ACOMM–– MCA branchesMCA branches–– Basilar TipBasilar Tip

13


Angiography Angiography -- AngiogramAngiogram

AP

Oblique


ICA AneurysmICA Aneurysm


Bilateral Carotid AneurysmsBilateral Carotid Aneurysms


Pulsation Artifact

Phase-encoding direction


ICA AneurysmICA Aneurysm


Superficial SiderosisSuperficial Siderosis

14



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– MetastaticMetastatic–– PrimaryPrimaryInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– MetastaticMetastatic

Lung, Breast, Renal, Melanoma, Lung, Breast, Renal, Melanoma, ChoriocarcinomaChoriocarcinoma

InfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations


Hemorrhagic MetastasesHemorrhagic Metastases

Hemorrhagic Melanoma Metastasis

Melanoma Metastasis


Mets: Distributed by BloodMets: Distributed by Blood

Greatest Blood FlowGreatest Blood Flow–– supratentorialsupratentorial–– MCA territoryMCA territory

Greatest FiltrationGreatest Filtration–– GrayGray--White JunctionWhite Junction–– Abrupt Change in Size & Number of Abrupt Change in Size & Number of

VesselsVesselsHematogenous Particles park at vessel branching points …

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Multifocal Multifocal NodularNodular LesionsLesions

All Near Gray matter: cortex and basal ganglia

15



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– PrimaryPrimary

GBM, Oligodendroglioma, Pituitary, CNC, PCNSLGBM, Oligodendroglioma, Pituitary, CNC, PCNSL

InfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations


6/157/22

Courtesy of R.D. Zimmerman, NY



OligodendrogliomaOligodendroglioma

Spontaneous Hemorrhage from fine vesselsSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Oligodendroglioma Oligodendroglioma -- BleedBleed

16


Pituitary MACROPituitary MACRO--AdenomaAdenoma



Pituitary AdenomaPituitary AdenomaAdult PatientAdult PatientMicroadenomaMicroadenoma–– < 10 mm< 10 mm–– entirely within glandentirely within gland–– Endocrine Sx.Endocrine Sx.

Prolactinoma Prolactinoma AcromegalyAcromegalyGigantismGigantismCushing DiseaseCushing Disease

MacroadenomaMacroadenoma–– > 10 mm> 10 mm–– balloon sellaballoon sella–– Visual SxVisual Sx

if >6 mm above sellaif >6 mm above sellabitemporal hemianopsiabitemporal hemianopsia Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Pituitary ApoplexyPituitary ApoplexyMet Hemoglobin in

Pituitary Macroadenoma


Met Hemoglobin in Pituitary

Macroadenoma


17


David and GoliathDavid and GoliathDid Goliath have Gigantism and/or Did Goliath have Gigantism and/or Acromegaly?Acromegaly?He was a He was a ““GiantGiant””He was an Angry Giant from HA and ICPHe was an Angry Giant from HA and ICPDid he have a Macroadenoma?Did he have a Macroadenoma?–– David was able to sneak up to himDavid was able to sneak up to him

bitemporal hemianopsiabitemporal hemianopsia““Tunnel VisionTunnel Vision””

–– One stone to the head killed himOne stone to the head killed himPituitary ApoplexyPituitary ApoplexyHemorrhage into a macroadenomaHemorrhage into a macroadenoma Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Neoplasms w/HemorrhageNeoplasms w/Hemorrhage

GlioblastomaGlioblastomaOligodendrogliomaOligodendrogliomaPituitary AdenomaPituitary AdenomaCentral NeurocytomaCentral NeurocytomaMetastasesMetastases–– Lung, Breast, Renal, Melanoma, Thyroid, Lung, Breast, Renal, Melanoma, Thyroid,

ChoriocarcinomaChoriocarcinoma



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectious–– Necrotizing Encephalitis (Herpes Simplex)Necrotizing Encephalitis (Herpes Simplex)–– AngioinvasiveAngioinvasive Organism (Organism (aspergillusaspergillus, , mucormucor))–– MycoticMycotic AneurysmAneurysm

VasculopathyVasculopathyVascular MalformationsVascular Malformations


HSV EncephalitisHSV Encephalitis


Hemorrhagic Necrosis and AtrophyHemorrhagic Necrosis and Atrophy

PetechialHemorrhages

PetechialHemorrhages


Serpentine Serpentine -- Cortical GyralCortical Gyral

Encephalitis Meningo-EncephalitisMeningitis

18


HSV Encephalitis HSV Encephalitis -- FLAIRFLAIR


HSV Encephalitis HSV Encephalitis –– T1WGd+T1WGd+


HSV Encephalitis HSV Encephalitis –– T2WT2W

Hemosiderin


HSV Encephalitis HSV Encephalitis –– T1WGd+T1WGd+


HSV Encephalitis HSV Encephalitis –– T1WT1W

Met Hemoglobin in Cortical Petechial

Hemorrhages


AngioinvasiveAngioinvasive InfectionsInfections

Usually immune suppressedUsually immune suppressed–– AIDSAIDS–– Chronic Diseases (Diabetes)Chronic Diseases (Diabetes)

Organism causes thrombosis, or breaks Organism causes thrombosis, or breaks down vessel walls, causing hemorrhagedown vessel walls, causing hemorrhageTypical fungal organismsTypical fungal organisms–– AspergillusAspergillus: : fumigatusfumigatus (highly aerobic mold)(highly aerobic mold)–– ZygomycetesZygomycetes: e.g. : e.g. MucormycosisMucormycosis

19


MucormycosisMucormycosis BG Infarction BG Infarction with Secondary Hemorrhagewith Secondary Hemorrhage



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathy–– Hypertension, Hypertension, AmyloidAmyloid, Atherosclerosis, , Atherosclerosis,

Dissection, Autoimmune, InfarctionDissection, Autoimmune, Infarction

Vascular MalformationsVascular Malformations


Hemorrhagic Embolic InfarctionHemorrhagic Embolic Infarctionvs.vs.

Hemorrhagic ConversionHemorrhagic Conversionvs.vs.

Venous InfarctionVenous Infarction


CEREBROVASCULAR DISEASE:CEREBROVASCULAR DISEASE:““Hemorrhagic InfarctionHemorrhagic Infarction””

ARTERIAL ETIOLOGYARTERIAL ETIOLOGY–– Embolic Occlusion (MCA)Embolic Occlusion (MCA)–– Herniation (PCA, Herniation (PCA, AChoAAChoA))VENOUS ETIOLOGYVENOUS ETIOLOGY–– Sinus Thrombosis (SSST)Sinus Thrombosis (SSST)–– Deep infarcts in strips, parallel falxDeep infarcts in strips, parallel falxCONVERSION in ISCHEMIC INFARCTCONVERSION in ISCHEMIC INFARCT–– Large Infarcts (whole MCA)Large Infarcts (whole MCA)--Anticoagulation (incl. ASA and Anticoagulation (incl. ASA and thrombolysisthrombolysis))


20

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008NCT

Reperfusion InjuryReperfusion Injury

ECTHemorrhagic Infarction


Hemorrhagic InfarctionHemorrhagic Infarction




Herniation and PCA InfarctionHerniation and PCA Infarction

Superior Cerebellar a.Superior Cerebellar a.OculomotorOculomotor nerve (CN3)nerve (CN3)TrochlearTrochlear nerve (CN4)nerve (CN4)Posterior Cerebral Posterior Cerebral aaaa..Temporal Lobe HerniationTemporal Lobe Herniation–– Compresses CN3/4Compresses CN3/4–– Compresses PCACompresses PCA

Slow flow allows bleedingSlow flow allows bleeding


PCA Infarct Tentorial HerniationPCA Infarct Tentorial Herniation

Courtesy Mauricio Castillo, M.D. UNC

21


PCA Infarct from HerniationPCA Infarct from HerniationAnterior ChoroidalArtery Infarction


Anterior ChoroidalArtery Infarction

Contusion vs. Hemorrhagic InfarctionContusion vs. Hemorrhagic Infarction

Cortical Gray to Depth of SulcusPCA Infarction


Plain T1W MRPlain T1W MR


T1W PD



PD T2W



Normal vs. Venous Outflow Normal vs. Venous Outflow ObstObst..

Deoxygenated blood

Stagnates in capillary bed

22


MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin IsoIso IsoIsoDeDe--oxy Hgboxy Hgb IsoIso (1(1--3hr)3hr) LowLow (2hr)(2hr)

MetMet--Hgb (in cells)Hgb (in cells) HiHi (3(3--14hr)14hr) LowLow

MetMet--Hgb (in soln.) Hgb (in soln.) HiHi HiHi (hrs(hrs--wks)wks)

HemichromesHemichromes LowLow LowLowHemosiderinHemosiderin LowLow LowerLower Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Hemorrhagic transformationHemorrhagic transformation

Initial CT 24 hours laterInitial CT 24 hours laterHerniation PCA compression & Bilateral Occipital Infarcts


Carotid Thrombosis => Carotid Thrombosis => MCA ClotMCA Clot

MCAACA

MCA

PCA

X


medpix20366.jpgThis 53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body weakness


medpix20367.jpg

Repeat CT scans, two hours after admissionSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008

medpix20375.jpg

DWI ADC Map

ALWAYS compare w/ADC MapALWAYS compare w/ADC Map

23


Two days after IA Thrombolysis

Thrombotic Cerebral InfarctionThrombotic Cerebral Infarction


Venous Thrombosis and InfarctionVenous Thrombosis and Infarction


T2W

CT @ 20º MR @ 0º

CTDeep hemorrhage into dead white-mater may spare cortex


Superior Sagittal Sinus ThrombosisSuperior Sagittal Sinus Thrombosis


Superior Sagittal Sinus Superior Sagittal Sinus ThrombosisThrombosis


Sup. Sag. Sinus ThrombosisSup. Sag. Sinus Thrombosis

DehydrationDehydrationParaneoplastic Syndromes w/hypercoagParaneoplastic Syndromes w/hypercoagSpinal AnesthesiaSpinal AnesthesiaPostPost--partumpartum

24


CEREBROVASCULAR DISEASE:CEREBROVASCULAR DISEASE:HYPERTENSIONHYPERTENSION

Hypertensive Hematoma (Hemorrhage)Hypertensive Hematoma (Hemorrhage)Lacunar InfarctionLacunar Infarction


•Spontaneous Arteriolar Occlusion-lacunar infarcts

•Spontaneous Rupture-”hypertensive hemorrhage”

•Ectatic Elongation-Etat Crible

CEREBROVASCULAR DISEASEArteriolar Sclerosis


ARTERIOLOSCLEROSISARTERIOLOSCLEROSIS

Hyaline arteriolosclerosisHyaline arteriolosclerosisHyperplastic arteriolosclerosisHyperplastic arteriolosclerosis"Lipohyalinosis""Lipohyalinosis"



HYPERTENSIVE CVDHYPERTENSIVE CVD

Arteriolar occlusion Arteriolar occlusion -- ischemiaischemia(Lacunae, Binswanger)(Lacunae, Binswanger)Arteriolar rupture Arteriolar rupture -- hemorrhagehemorrhage(Hematoma(Hematoma--BG, Thal., etc.)BG, Thal., etc.)Etat Crible (Dilated VEtat Crible (Dilated V--R)R)(status cribrosus/cribalis)(status cribrosus/cribalis)


CEREBROVASCULAR DISEASECEREBROVASCULAR DISEASEArteriolar SclerosisArteriolar Sclerosis

LACUNAE (Lacunar Infarcts)LACUNAE (Lacunar Infarcts)--MultipleMultiple--Small cavities (1Small cavities (1--15 mm.)15 mm.)--Deep Gray and White:Deep Gray and White:PutamenPutamen, Thalamus, Internal , Thalamus, Internal Capsule, PonsCapsule, PonsPure Motor Pure Motor HemiplegiaHemiplegiaArteriolosclerosis (HT)Arteriolosclerosis (HT)

25


ARTERIOLOSCLEROSISARTERIOLOSCLEROSIS


Old Old LacunarLacunar Infarcts in GPInfarcts in GP


HT HEMORRHAGEHT HEMORRHAGE

PutamenPutamen 55%55%CerebrumCerebrum 15%15%ThalamusThalamus 10%10%Pons Pons 10%10%CerebellumCerebellum 10%10%


HT BLEEDHT BLEED

Ateriolar SclerosisAteriolar Sclerosis–– Hyaline arteriolosclerosisHyaline arteriolosclerosis–– HyperplasticHyperplastic arteriolosclerosisarteriolosclerosis–– ""LipohyalinosisLipohyalinosis""Penetrating and nonPenetrating and non--anastomoticanastomoticendend--arteries and arteriolesarteries and arteriolesDeep Gray (Nuclear) AreasDeep Gray (Nuclear) Areas


Hypertensive HemorrhageHypertensive Hemorrhage

BP on presentation 185/105

Courtesy Doug Phillips, UVA

26


INTRAINTRA--CEREBRAL CEREBRAL HEMORRHAGEHEMORRHAGE

Dense and HomogeneousDense and HomogeneousRound/oval shapeRound/oval shapeBasal ganglia/deep whiteBasal ganglia/deep whiteProportional mass effectProportional mass effectExtension into ventricleExtension into ventricle





Usually single eventUsually single eventHA, Pure motor HA, Pure motor hemiplegiahemiplegia, etc., etc.Expanding clot will displace white matterExpanding clot will displace white matterLocal tissue pressure Local tissue pressure tamponadetamponade stops bleedingstops bleedingTreatment is often supportiveTreatment is often supportive–– Herniation and deterioration prompt surgeryHerniation and deterioration prompt surgery

Clot liquefies and is largely absorbedClot liquefies and is largely absorbedHemosiderin ringHemosiderin ring


Hypertensive HematomaHypertensive Hematoma


Hypertensive HematomaHypertensive Hematoma

Circumscribed Mass Pushing Margin


3 mo. p/Hypertensive Hemorrhage3 mo. p/Hypertensive Hemorrhage

27



Hemosiderin





Hemosiderin


81 81 y.oy.o. woman BP 200 mm Hg. woman BP 200 mm Hg


28


6 days p/Hypertensive Bleed6 days p/Hypertensive Bleed

Met Hemoglobin



Hemosiderin



Met Hemoglobin



BP on presentation 210/110




Hypertensive “hit list”External CapsuleThalamusDentate NucleusPonsLobar

*

Courtesy Doug Phillips, UVA Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Hemorrhage into a massHemorrhage into a massAcute hemiplegia and confusion in a 68 year old man


NOTE: Vasogenic Edema

29


GBMGBM

Courtesy Doug Phillips, UVA Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008

Pt acutely agitatedPt acutely agitatedMass EffectMass Effect

Hypertensive Bleed vs. CCMHypertensive Bleed vs. CCMPt with only HAPt with only HAMinimal mass effectMinimal mass effect


CCM Has Complex Blood ProductsCCM Has Complex Blood Products

Minimal mass effect, at presentation, blood products already complex with both methemoglobin (bright) and hemosiderin (dark)


AmyloidAmyloid AngiopathyAngiopathy


Arteriolosclerosis vs. Arteriolosclerosis vs. AmyloidAmyloid

Long standing HTLong standing HTLocation:Location:–– Basal Ganglia, Basal Ganglia,

Thalamus, BrainstemThalamus, Brainstem

Single EventSingle Event

+/+/-- HypertensionHypertensionLocation:Location:–– Usually LobarUsually Lobar–– Often Often MultificalMultifical

Multiple EventsMultiple Events–– Can be bilateralCan be bilateral


Mar 11 Mar 30

Mar 13

30




Extensive Amyloid, Acute BleedExtensive Amyloid, Acute Bleed

MRI - T2* CTCourtesy Howard Rowley, M.D.

31


Cerebral Cerebral amyloidamyloid angiopathyangiopathy

Extracellular deposition of Extracellular deposition of amyloidamyloid in the walls of in the walls of brain and brain and meningealmeningeal blood vesselsblood vessels17 biochemically distinct forms of 17 biochemically distinct forms of amyloidamyloidBB--APP, APP, CystatinCystatin C, British protein involvedC, British protein involvedAmyloidAmyloid fibrils show fibrils show BB--Pleated sheet Pleated sheet secondary structuresecondary structureStains: Congo red, PAS, Stains: Congo red, PAS, ThyoflavinThyoflavin S or TS or T



Involvement of small arteries and Involvement of small arteries and arterioles of cerebrum, cerebellum and arterioles of cerebrum, cerebellum and leptomeningesleptomeningesPathological changesPathological changes–– FibrinoidFibrinoid necrosisnecrosis–– MicroaneurysmsMicroaneurysms



Alzheimer diseaseAlzheimer diseaseLobar hemorrhageLobar hemorrhage–– SporadicSporadic–– FamilialFamilial

Ischemic infarct in ADIschemic infarct in ADIschemic infarct in nonIschemic infarct in non--demented demented patientspatients

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy Vince Mathews, M.D.

Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy Vince Mathews, M.D.


MicrobleedsMicrobleeds vs. Cavernous Malformationsvs. Cavernous Malformations

Courtesy Vince Mathews, M.D.

“microbleeds” are BLACK … cavernous malformations are complex Black & White

32


Arteriolosclerosis vs. Arteriolosclerosis vs. AmyloidAmyloid

Long standing HTLong standing HTLocation:Location:–– Basal Ganglia, Basal Ganglia,

Thalamus, BrainstemThalamus, Brainstem

Single EventSingle Event

+/+/-- HypertensionHypertensionLocation:Location:–– Usually LobarUsually Lobar

Often multiple and Often multiple and progressiveprogressive–– Can be bilateralCan be bilateral



TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations–– Covered by Dr. SmithCovered by Dr. Smith


SummarySummary

Hemorrhage has many causesHemorrhage has many causesHemorrhage has many locationsHemorrhage has many locationsHemorrhage has a variable appearanceHemorrhage has a variable appearance–– Especially on MRIEspecially on MRI


Location of HemorrhageLocation of Hemorrhage

Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid


Appearance of HemorrhageAppearance of Hemorrhage


Thank You!Thank You!

Muito Obrigado

EUXAPIΣTΩ !Mahalo !

Dank u wel !Merci Beaucoup

Danke Schön !

Muchas Gracias

Go Raibh Maith Agat

ありがとうございます。感謝いたします。

Documents

Intracranial Hemorrhage I’m from the Government … … and I ... · 1 Intracranial Hemorrhage James G. Smirniotopoulos, M.D. Uniformed Services University Bethesda, MD Smirniotopoulos