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Intracranial Hemorrhage on Intracranial Hemorrhage on CT CT
Tobias Potzger Tobias Potzger (Ludwig(Ludwig--MaximiliansMaximilians--University Munich)University Munich)
Gillian Lieberman, MDGillian Lieberman, MD
June 2008June 2008
AgendaAgenda
Review of Review of neuroanatomyneuroanatomy
CTCT-- appearance of intracranial appearance of intracranial hemorrhagehemorrhage
Patient presentationPatient presentation
Appearance of cerebral edema and Appearance of cerebral edema and herniationherniation
Review AnatomyReview Anatomy
Meninges of the brain(1)
Arterial SystemArterial System
(2)
(6)
Venous SystemVenous System
(6)
Venous SystemVenous System
Gray`s figure 570#, 578#
CerebrospinalCerebrospinal--Fluid SystemFluid System
Cerebrospinal-Fluid System (3)
CerebrospinalCerebrospinal--Fluid FlowFluid Flow
(7)(13)
Our Patient: History Our Patient: History
History:History:49 year old man49 year old manNo significant No significant PMHxPMHxInvolved in several low speed Involved in several low speed accidentsaccidentsSlurred speech/word substitutionsSlurred speech/word substitutionsdisorientationdisorientation
Our Patient examinationOur Patient examination
Outside Hospital ED 1Outside Hospital ED 1stst day:day:No feverNo feverNo headache, no neck stiffness, no No headache, no neck stiffness, no photophobia or visual changesphotophobia or visual changesWBC 7,9 WBC 7,9 CTCT
Our Patient: Head CTOur Patient: Head CT
(14)
No significant findings
Our Patient CourseOur Patient Course
No significant CTNo significant CT--head findingshead findings
Return to normal mental statusReturn to normal mental status
Patient was discharged from the EDPatient was discharged from the ED
Advantages Advantages Head Head CT CT
Detects acute bleedingDetects acute bleeding
FastFast
Simultaneous assessment of bone Simultaneous assessment of bone and brain tissue and brain tissue
Availability Availability
Appearance of Hemorrhage on Appearance of Hemorrhage on CTCT
<12h<12h isodenseisodense12h 12h -- 7d 7d hyperdensehyperdense7d 7d –– 1 month 1 month isodenseisodense> 1 month> 1 month isodenseisodense hypodensehypodense
Epidural Hemorrhage (EDH) on CTEpidural Hemorrhage (EDH) on CT
(BIDMC)
Companion Patient 1Companion Patient 1
Axial, CCT C-
Epidural Hemorrhage: FactsEpidural Hemorrhage: Facts11--4% of patients with intracranial trauma4% of patients with intracranial trauma8585--95% middle 95% middle meningealmeningeal artery or a artery or a duralduralvenous sinus venous sinus 95% unilateral and 95% unilateral and supratentorialsupratentorial66% of acute epidural hematomas are 66% of acute epidural hematomas are hyperdensehyperdense on CTon CT33% contain 33% contain hypodensehypodense areas secondary to areas secondary to active bleedingactive bleedingLucid intervalLucid intervalDoes not cross suture marginsDoes not cross suture marginsMidline shiftMidline shift
Subdural Hemorrhage (SDH) on CTSubdural Hemorrhage (SDH) on CT
(5)Axial CCT, C-
Companion Patient 2Companion Patient 2
Subdural Hemorrhage: FactsSubdural Hemorrhage: Facts
most common extramost common extra--axial collectionaxial collectionseen in 5% of head trauma patientsseen in 5% of head trauma patientsUsually due to traumatic bleeding Usually due to traumatic bleeding from the "bridging" subdural veinsfrom the "bridging" subdural veinstend to conform to the shape of the tend to conform to the shape of the brainbrainCrescent shapeCrescent shapeCan cross suturesCan cross suturesMidline shiftMidline shift
Subdural HemorrhageSubdural Hemorrhage
Crescent shape
Midline Shift
(5)
Companion Patient 2
Axial CCT, C-
Subarachnoid Hemorrhage (SAH) Subarachnoid Hemorrhage (SAH) on CTon CT
(7)
Companion Patient 3Companion Patient 3
Axial, CCT C-
Subarachnoid Hemorrhage: FactsSubarachnoid Hemorrhage: Facts
Most frequent causes:Most frequent causes:Head trauma Head trauma Intracranial aneurysms (80% of Intracranial aneurysms (80% of nontraumatic)nontraumatic)Most occur around the circle of Willis Most occur around the circle of Willis (berry aneurysm) at (berry aneurysm) at
Middle cerebral artery bifurcation Middle cerebral artery bifurcation Anterior communicating artery Anterior communicating artery Posterior communicating artery Posterior communicating artery
Berry AneurysmBerry Aneurysm
(10) (11)
Subarachnoid Hemorrhage: FactsSubarachnoid Hemorrhage: Facts
Less frequent causes:Less frequent causes:•• Arteriovenous malformation (AMV)Arteriovenous malformation (AMV)•• Extension from intracerebral Extension from intracerebral
hemorrhagehemorrhage•• Arteriovenous fistulae Arteriovenous fistulae •• Meningitis Meningitis •• NeoplasmNeoplasm
SAH Clinical FindingsSAH Clinical Findings
Headache (Headache (““worst headache of lifeworst headache of life””))NauseaNauseaVomitingVomitingDisorientation, confusionDisorientation, confusion
SAHSAH
Attenuation blood is noted in the:
- Suprasellar cistern
- Sylvian fissur
- Interpeduncular cistern
(7)Axial CCT, C-
Companion Patient 3
Our Patient followOur Patient follow--upup
10 h later/ 210 h later/ 2ndnd day:day:patient was found unresponsive and patient was found unresponsive and pulslesspulsless (max. 15min)(max. 15min)CPR, defibrillation x1CPR, defibrillation x1Transport to outside hospitalTransport to outside hospital-- hypotensivehypotensive, hypothermic and , hypothermic and unresponsiveunresponsive-- PH 6.7, WBC 8.3, Cr 1.8, PH 6.7, WBC 8.3, Cr 1.8, CTCT followfollow--upup
Our PatientOur Patient FollowFollow--up CCTup CCT
(14)
Our PatientOur Patient Initial vs. FollowInitial vs. Follow--up CCTup CCT
11stst day day 22ndnd dayday
(14)
Our Patient CTOur Patient CT--work upwork up
Loss of gray/white Loss of gray/white differentiationdifferentiationDecrease volume Decrease volume of CSFof CSF--spacesspacesLess prominent Less prominent gyrigyri and and sulcisulci
Cerebral edemaCerebral edema
(14)
Cerebral edemaCerebral edemaDefinitionDefinition: increase in the fluid content of the brain: increase in the fluid content of the brain
A. A. VasogenicVasogenic Cerebral EdemaCerebral Edema (most common form of edema): (most common form of edema): •• 1. Increased permeability of small vessels (breakdown of blood1. Increased permeability of small vessels (breakdown of blood--brain brain
barrier)barrier)
•• 2. Escape of proteins, fluids into extracellular space, especial2. Escape of proteins, fluids into extracellular space, especially of ly of white matter white matter
B. B. CytotoxicCytotoxic Cerebral EdemaCerebral Edema (cellular brain edema): (cellular brain edema): •• 1. Increased permeability of cell membranes1. Increased permeability of cell membranes
•• 2. Excess fluid accumulates 2. Excess fluid accumulates intracellularlyintracellularly; may occur with ischemia or ; may occur with ischemia or with other conditions such as metabolic poisons or water intoxicwith other conditions such as metabolic poisons or water intoxication.ation.
••C. Hydrocephalic (Interstitial) Edema:C. Hydrocephalic (Interstitial) Edema:
•• 1. Fluid flows from CSF into brain through ventricular lining in1. Fluid flows from CSF into brain through ventricular lining in cases of cases of hydrocephalus. hydrocephalus.
All can cause herniationAll can cause herniation
HerniationHerniationSite of herniationSite of herniation Structures involvedStructures involved SignsSigns
Lateral tentorial (uncal)Lateral tentorial (uncal) IIIIII Cerebral peduncleCerebral peduncle Posterior cerebral arteryPosterior cerebral artery
PtosisPtosis, , mydriasismydriasis, lateral , lateral deviation of eyedeviation of eye HemiparesisHemiparesis, , HemianopiaHemianopia
Posterior tentorial (tectal)Posterior tentorial (tectal) Tectal plate (post Tectal plate (post commissure, sup colliculi)commissure, sup colliculi)
Bilateral Bilateral ptosisptosis, failure of , failure of upgazeupgaze
Central tentorialCentral tentorial (axial brainstem)(axial brainstem)
Reticular formationReticular formation CorticospinalCorticospinal tractstracts Midbrain and Midbrain and ponspons
MedullaMedulla
¯̄ consciousnessconsciousness DecerebrateDecerebrate rigidityrigidity ¯̄ or absence of eye or absence of eye movement reflexes, movement reflexes, irregular respirationirregular respiration -- BP, BP, ¯̄ HR, irregular HR, irregular respiration, respiration, apnoeaapnoea
Foramenal (tonsillar)Foramenal (tonsillar) MedullaMedulla ApnoeaApnoea
Subfalcine (cingulateSubfalcine (cingulate Cingulate gyrus, anterior Cingulate gyrus, anterior cerebral arterycerebral artery
Leg weaknessLeg weakness
(9)
Our PatientOur Patient
Patient was transported to BIDMCPatient was transported to BIDMC
BP 90/37, pulse 84, RR 12 and O2 BP 90/37, pulse 84, RR 12 and O2 85%85%
PupillaryPupillary reflex, corneal reflex and reflex, corneal reflex and gag reflexes gag reflexes unreactiveunreactive
Our Patient with Subarachnoid Our Patient with Subarachnoid hemorrhage on CThemorrhage on CT
(BIDMC)
Our Patient: SAH ProgressionOur Patient: SAH Progression
(14), (BIDMC)
Initial film 12h later 14h later
Our Patient with Subarachnoid hemorrhage on CT
(BIDMC)
Subarachnoid hemorrhage
Patient died 2h after arrival at BIDMC-ED
Thanks to:Thanks to:-- Gillian Lieberman, MDGillian Lieberman, MD-- Rich Rich RanaRana, MD, MD-- Andrew Bennett, MDAndrew Bennett, MD
AcknowledgementsAcknowledgements
ReferencesReferencesOestmannOestmann JoergJoerg W.,RadiologieW.,Radiologie VomVom Fall Fall zurzur Diagnose, 2. Diagnose, 2. AuflAufl. . ThiemeThieme
20052005Curtis A. Given Curtis A. Given II,PseudoII,Pseudo--Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: ApotentialApotential Pitfall Pitfall
Associated with Diffuse Cerebral Edema, Am. J. Associated with Diffuse Cerebral Edema, Am. J. NeuroradiolNeuroradiol 24:25424:254-- 256, February 2003256, February 2003
1. 1. http://http://www.sbsdefense.com/Subdurals.htmlwww.sbsdefense.com/Subdurals.html2. 2. http://http://webanatomy.netwebanatomy.net/anatomy//anatomy/3. 3. http://http://www.octc.kctcs.eduwww.octc.kctcs.edu4. 4. http://brighamrad.harvard.edu/Cases/bwh/hcache/100/full.htmlhttp://brighamrad.harvard.edu/Cases/bwh/hcache/100/full.html5. 5. http://brighamrad.harvard.edu/Cases/bwh/hcache/15/full.htmlhttp://brighamrad.harvard.edu/Cases/bwh/hcache/15/full.html6. 6. http://http://webanatomy.net/anatomy/circle_of_willis.jpgwebanatomy.net/anatomy/circle_of_willis.jpg7. 7. http://www.br13.com/assets/images/cerebrospinal_fluid.jpghttp://www.br13.com/assets/images/cerebrospinal_fluid.jpg8.8.http://www.neuroradiologyportal.com/articles/semneuro_files/imaghttp://www.neuroradiologyportal.com/articles/semneuro_files/imagee
005.jpg005.jpg9. 9. http://www.aic.cuhk.edu.hk/web8/cerebral_oedema.htmhttp://www.aic.cuhk.edu.hk/web8/cerebral_oedema.htm
References 2References 210. 10. http://geekbaby.files.wordpress.com/2007/06/berry.jpghttp://geekbaby.files.wordpress.com/2007/06/berry.jpg11. 11. www.neurosurgeryroseburg.comwww.neurosurgeryroseburg.com13. 13. http://webeye.ophth.uiowa.edu/ips/IIH/2_iih.jpghttp://webeye.ophth.uiowa.edu/ips/IIH/2_iih.jpg14. Caritas Good Samaritan Hospital, Dept. of Radiology14. Caritas Good Samaritan Hospital, Dept. of Radiology