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INTRODUCTION& PATHOGENESIS PATHOGENESIS OF HYPERTENSIVE

CEREBRAL HEMORRHAGE PATHOLOGY CT SCAN IMAGING OF CEREBRAL

HEMORRHAGE MR IMAGING OF CEREBRAL

HEMORRHAGE CEREBRAL EDEMA ASSOCIATED WITH

NONTRAUMATIC CEREBRALHEMORRHAGE

REFERENCES

RADIOLOGICAL PATHOLOGY OF MICROVASCULAR CEREBRALHAEMORRHAGE:

Haemorrhagic microvascular brain disease constitutes the other facet of the bad coin (themicrovascular brain disease) the first facet of which is the ischemic microvascular braindisease. Both the haemorrhagic and the ischaemic microvascular brain disease sharecommon haemorheological, metabolic endocrinal abnormalities (The metabolic syndrome)and cardiac changes(LVH).

In microvascular brain disease, the small penetrating arterioles of the subependymal andthe pial microvascular systems tend to become stenosed and undergo lipohyalinosis or theymay dilate to form microaneurysms. From the pathological point of view both

Lipohyalinosis and microaneurysms, almost invariably, coexist in the same individual, thusmaking the patient Liable to develop either the ischaemic or the haemorrhagicmicrovascular brain.

Figure 1.Microaneurysms of the smallpenetratingarterioles

Microaneurysmal formation occurs predominantly in the territory of the subependymalmicrovascular system,thus making the incidence of the haemorrhagic microvascular eventsmuch more frequent in the periventricular gray matter (thalamus, basal ganglia and theinternal capsule) or the immediate periventricular white matter. The coexistence oflipohyalinosis and microaneurysms in the periventricular regions will explain thepropensity of the diseased microvascular system either to thrombose (resulting in lacunarinfarctions) or to rupture and leak resulting in periventricular haematoma formation.Lacunar infarctions and hypertensive cerebral haemorrhages are two facets of one and thesame bad coin (the microvascular brain disease).

Figure 2. Microaneurysms are predominately distributed in the immediate periventricular region

Microaneurysmal formation should weaken the arteriolar wall so that rupture and leakagecan occur even in normotensive states. When microaneurysmal rupture occurs, thebleeding will result in haematoma formation. The bleeding will then be arrested byocclusive thrombosis of the bleeding microaneurysms. Following microaneurysmal ruptureand bleeding, the size of the resulting haematoma will be determined by the bleeding time.The bleeding time is a function of the whole blood viscosity in general and the plateletaggregability in particular.

Should microaneurysmal bleeding occurs during periods of higher blood viscosity, thebleeding time will be shorter and subsequently the size of the resulting haematoma will besmaller. In fact during high blood viscosity the bleeding is not infrequently arrested beforeforming haemorrhages adequate to give rise to immediate clinical sequelae. Patients withhigher blood viscosity and thrombotic tendency, although less likely to develop serioushaemorrhagic microvascular events, they are particularly liable to develop seriousischaemic microvascular events.

During periods of lower blood viscosity and thrombotic tendency of the blood,microaneurysmal bleeding might result in huge haematoma formation that may split alongthe planes of the white matter forming a substantial space occupying clot, or may ruptureinto the ventricular system resulting in massive ventricular haemorrhage. In generalinverse correlation is present between the haematoma size and the current blood viscosityat the time of microaneurysmal bleeding.

Patients with microvascular brain disease might have recurrent events which could bepurely haemorrhagic or purely ischaemic, however, it is not uncommon for some patientsto fluctuate between the haemorrhagic and the ischaemic events, developing haemorrhagicevents at certain times and ischaemic events at other times. In general ischaemicmicrovascular events are much more common and much more frequent than thehaemorrhagic events.

PATHOGENESIS OF HYPERTENSIVE CEREBRAL HEMORRHAGE

Hypertension causes fibrinoid necrosis of these penetrating arterioles. The massiveintracerebral hemorrhage which is a complication of hypertension, arises from rupture of anecrotic arteriole or from rupture of a minute "miliary" aneurysm formed at the site ofnecrosis. These aneurysms were first described by CHARCOT and BOUCHARD. Thefrequency of fibrinoid necrosis and miliary aneurysm formation in vessels within basalganglia and thalamus accounts for the frequency of intracerebral hemorrhage in thoselocations. Fibrinoid is identified by its structureless or sometimes granular red appearanceon H&E stain and by the fact that , unlike hyalinized smooth muscle which is alsoeosinophilic, the fibrinoid areas stain with stains for fibrin such as PTAH or Putz stain orwith certain trichrome stains. The fibrinoid change in these vessels was calledlipohyalinosis by Miller-Fisher in a very influential series of articles. However that term isconfusing because hyalinized arteries are arteries whose media has undergone a pathologicchange which is not fibrinoid necrosis and which by itself does not lead to rupture. Indeedhyalinized arterioles are common in hypertension. The term lipohyalinosis stresses thepresence of fat in the degenerate arteriolar wall but again this change is not the hallmark ofthe arterioles that are in danger of rupturing or forming miliary aneurysms. The fibrinoidchange is the critical change in these diseased arteriolar segments looks and stains just likethe fibrinoid seen in renal and other arterioles in malignant hypertension. The importantpoint to remember is that, for unknown reasons, the brain arterioles can undergo fibrinoidnecrosis even in so-called benign hypertension--that is in patents with only modest bloodpressure elevation. For that reason it is important to treat even benign hypertension. Theseries figures below illustrates the pathologic processes that can lead to rupture.

Figure 3. A, The figure shows the wall of an arteriole stained with H&E. The amorphouspink [eosinophilic] material in the wall could be either fibrinoid or amyloid. To prove thatit is firbrinpoid the section or its close neighbor should be stained with any one of severaltechniques that stain fibrin [e.g. Putz stain-blue; or the PTAH stain-blue; or a trichromestain such as the azo carmine stain; the azo carmine is particularly good because itdistinguishes fibrinoid from garden variety hyalinization by staining fibrin/fibrinoid redwhile staining collagen or hyalinized collagen blue.]. B, This section was stained withazocarmine. An arteriole in the subarachnoid space has an amorphous red materialoccupying a good portion of its wall. This is fibrinoid. Fibrinoid is frequently segmental indistribution so that the entire circumference may not be involved and other areas along thelength of the vessel may also be spared. C, This figure was also stained with azocarmine.The arteriole wall is replaced by red fibrinoid and displays aneurysmal dilation.

Figure 4. A,B Sometimes a miliary aneurysm thrombosis rather than ruptures. It thenappears as a fibrous ball which may be separated from the parent vessel due to the plane atwhich the section has been cut. If the section is close to the parent arteriole there will beelastic tissue at the margin of the ball. This elastic tissue stains black with the VVG stain in(B)

Figure 5. The pathologist gotlucky when this section wastaken. Here a miliary aneurysmthat has neen converted to afibrous ball or globe, shown inthis longitudinal section, stillconnected to the parentarteriole by a thin neck.

PATHOLOGY

Cerebral Haematomas occur much more frequently at the putameno-capsular and thethalamic regions and may rupture into the ventricular system. Less common sites includethe cortical and the immediate subcortical white matter, especially in the parietal region,the pons and the cerebellum.

The resulting haematoma is dark red in colour due to the existence of deoxyhaemoglobininside the intact RBCS. During the subacute stage (3 days - one month) the dark red colour

of the haematoma is replaced by a brownish discoloration, which starts at the periphery ofthe haematoma and then extends to its center. This brownish discoloration occurs due tothe replacement of deoxyhaemoglobin by the oxidized methemoglobin.

Acute hematoma usually spreads between white matter tracts resulting in island of viablebrain tissues within the hematoma itself. Bleeding usually stops shortly after the initialictus, however in a substantial minority of patients the hematoma continues to expandusually within the first hour after the presentation. Expansion after one hour is unusual.Once hematoma forms, vasogenic edema forms around the clot as osmotically active serumproteins are released from the hematoma. Edema peaks at about 48 hours and usuallybegins to resolve after 5 days. Whether the brain tissues surrounding the acute hematomais ischemic -due to vascular compression- or not is controversial. Functional suppression(diaschisis) of brain activity rather than ischemia is more probable.

Risk of Hematoma Enlargement

In nearly one quarter of initially alert patients presenting with spontaneous intracerebralhemorrhage, secondary deterioration in level of consciousness occurs within the first 24hours after onset. Hematoma expansion and edema formation are believed to be the majorfactors involved In several large prospective and retrospective studies, investigators haveevaluated the rate of hematoma enlargement after initial presentation and report ratesranging from 14 to 38% within the first 24 hours of admission.[27,28]

In their review of 627 patients with spontaneous intracerebral hemorrhage Fujii, et al..[27]reported that CT scanning within 24 hours of admission demonstrated enlargement of thehematoma in 14% of patients. Five factors were found to be associated with enlargement:admission shortly after onset of symptoms, heavy alcohol consumption, irregularly shapedhematoma, reduced level of consciousness, and low level of fibrinogen.

Figure 6. Cerebral (A) and pontine (B) acute haemorrhage, C, acute cerebellar hemorrhage

Gradually the haematoma is surrounded by reactive gliosis and macrophages laden withhaemosiderin granules (Ferric hydroxide). The clot is gradually absorbed starting with itsperiphery and is replaced by a yellow fluid, this is called an apoplectic cyst. Reactive gliosisprogressively increases and ultimately transforms the haematoma into a slit-like scar.

Figure 7. A, acute putameno-capsular & intraventricular hemorrhage, B, apoplectic cyst

Figure 8. A, Subacute caudate hemorrhage, B, apoplectic cyst, C, Hypertensivehemorrhage into basal ganglia region (specifically: internal capsule).

Pathologically the brains of patients with cerebral haemorrhages very frequently showevidence of past microvascular ischaemic events such as lacunar infarctions,leukoaraiosis,etc.

INCIDENCE OF COMMON ANATOMICAL SITES IN HYPERTENSIVEINTRACEREBRAL HAEMORRHAGE

Figure 9. Incidence (in % ) of the common anatomical sites in hypertensive intracerebralhaemorrhage

STRUCTURAL NEUROIMAGING OF MICROVASCULAR CEREBRALHAEMORRHAGE

CT imaging of haematoma.

A cerebral haematoma, in the acute stage, has higher attenuation values on precontrastscan (hyperdense). The higher attenuation values of fresh blood is due to the existence ofpacked haemoglobin in the haematoma. In particular the globin component of thehaemoglobin is responsible for the increased CT density on precontrast scan. Withprogressive absorption of haemoglobin, (this usually starts from the periphery of thehaematoma) the attenuation value of the haematoma gradually decreases until the highdensity haematoma is replaced by a low density space occupying cyst.

Figure 10. A, Acute haematoma, B, an apoplectic cyst and C, an old haematoma (slit-likescar)

The evolution of the haematoma from a high density clot to a low density cyst usually takesa period that ranges between one month to three months. The walls of this cyst mightenhance and the haematoma at this stage might be mixed with abscess or glioma. History isof paramount significance at this stage. Very old haematoma appears by CT scan as a slit-like hypodense area with negative mass effect.

In general Haematomas are space-occupying with positive mass effect and are commonlysurrounded by a hypodense oedema area. The most common sites are the putameno-capsular and the thalamic sites and either of them might rupture intraventricularly. Lesscommon sites includes the parietal lobe, pons and cerebellum.

The diagnosis of acute ICH is virtually 100% reliable with non-contrast CT due to thecharacteristic mass of blood of high attenuation value, due to the presence of the globincomponent of the haemoglobin molecule. Under exceptional circumstances, patients withprofound anaemia, with a haematocrit of 20% or less have presented with an acutehaematoma which was isointense to brain on account of the low haemoglobin contents ofthe fresh haematoma. Fresh blood has an attenuation value of 55-85 Hounsfield units, thehigh attenuation (50-70 Hounsfield units) is from high protein concentration within intactred blood cells and not iron content 1.

As the fresh clot starts to retract after 24-48 hours from onset, there is serum extrusionaround its periphery, resulting in a ring of hypointensity that surrounds the haematoma .In the subacute stage, the haematoma maintains its mass effect but becomes progressivelyless dense, from the periphery toward the center, until reaching isointensity with theadjacent brain parenchyma. The infusion of intravenous contrast at this stage candemonstrate an area of ring enhancement at the periphery of the haematoma. In thechronic stage, the mass effect of the haematoma is no longer present, post-contrastenhancement has disappeared after about 6 weeks from onset , and the residual is ahypointense cavity, at times in the form of a slit that can be indistinguishable from an areaof old cavitated infarction.

o More detailed description of the CT scan appearance of brain hemorrhage

The CT appearance of hemorrhage is determined by the degree of attenuation of the x-raybeam, which is proportional to the density of hemoglobin protein (relative to plasmaconcentration) within the hematoma.

Immediately following vessel rupture, the hematoma consists of a collection of red bloodcells, white blood cells, platelet clumps, and protein-rich serum that has a heterogeneousappearance on CT with attenuation in the range of 30–60 Hounsfield units (HU),depending on the degree of plasma extrusion [20]. In this hyperacute phase, hemorrhagemay be difficult to distinguish from normal cortex because of similar attenuation. Overminutes to hours, a fibrin clot forms with an increase in attenuation to 60–80 HU (Fig. 11)[20]. Clot retraction and extrusion of serum can further increase attenuation to as high as80–100 HU in the center of the hematoma. The degree of attenuation may be reduced inpatients with severe anemia [21], impaired clot formation due to coagulopathy, or volume

averaging with adjacent tissue. Vasogenic edema evolves around the hematoma withinhours and may continue to increase for up to 2 weeks after hemorrhage onset [22].

Figure 11. CT appearance of hemorrhage.Serial CT scans of right thalamic hematoma.(A) Acute ICH in the right thalamus withmean attenuation 65 HU. (B) CT performed 8days later than (A); the periphery of thehematoma is now isodense to the brain whilethe center of the hematoma has meanattenuation 45 HU. (C) CT performed 13 dayslater than (A) shows continued evolution ofthe hematoma with decreasing attenuation.(D) CT performed 5 months later than (A)shows a small area of encephalomalacia in thelocation of the previous hemorrhage.

Over the following days, cells and protein are broken down and scavenged bymacrophages, leading to slowly decreasing attenuation, with the greatest decrease at theperiphery of the hematoma and more gradual evolution toward the center (Fig. 11) [23].Within 4 to 9 days, the hematoma attenuation decreases to that of normal cortex, andwithin 2 to 3 weeks to that of normal white matter [20].

The CT recognition of subacute intracerebral hematoma can be challenging because theattenuation is similar to that of normal brain tissue, although mass effect may still bepresent. MR imaging can confirm subacute hematoma. As time goes on, attenuationcontinues to decrease to levels below that of the normal brain. Eventually, the hematomaresolves into a fluid-filled or slit-like cavity that may be difficult to visualize on CT (Fig.11). Contrast enhancement is not present in the initial days following ICH but may developat the periphery in weeks to months [24], sometimes leading to diagnostic confusion withbrain tumor or abscess.

A blood-fluid level may be seen in medium to large ICH within the first hours after onset;the dependent portion displays higher attenuation (Fig. 12) due to sedimentation of cellularelements [25]. This finding may be more common in ICH caused by anticoagulation [26],but it is not specific and has also been described in ICH due to hypertension, trauma,tumor, or arterial-venous malformation. The association with shorter time interval fromICH onset, and in some cases with anticoagulation, has led to speculation that incompleteclotting is required for blood-fluid level formation.

Figure 12. CT with blood-fluid level. A 77-year-old woman wasadmitted with coma of 4 hours' duration. CT scan showsmassive left hemispheric hematoma with blood-fluid level. Nohistory of anticoagulation or coagulopathy.

Box 1. As the hemorrhage evolves, different characteristic appearances can be identified onCT, depending on the age of the bleed. CT findings over time are as follows:

After 7-10 days, the high density of blood begins to decrease, starting from theperiphery of the lesion.

From 1-6 weeks, peripheral enhancement can be seen, mimicking the appearanceof an abscess, possibly related to hypervascularity at the periphery of a resolvinghematoma or disruption of the blood-brain barrier.

By 2-4 months, decreased density indicates cavity formation. A residual cavity isthe final stage, which is reached after complete absorption of necrotic andhemorrhagic tissue.

MRI Imaging of cerebral haematoma

Imaging of haematoma by MRI is time dependent as follow:

o The hyperacute stage (0 - 12 hour)

The acute hematoma less than 12 hours old is composed mostly of intracellularoxyhemoglobin with the edematous brain undergoing necrosis. 1 On T2-weighted MRimages, hyperacute hematoma will exhibit inhomogeneous signal due to hypointensedeoxyhemoglobin and hyperintense, edematous cortical tissue. MR is less sensitive than CTin the hyperacute stage because diamagnetic intra- cellular oxyhemoglobin lacks unpairedelectrons and thus clot signal is close to normal brain parenchyma- normal to slightly lowersignal on TI-weighted images and slightly higher signal on T2-weighted images 2,3. Repeatimaging is indicated to monitor the size of the hemorrhage and the development of delayedhemorrhage and vasogenic edema.

o The acute stage (12 Hr - 3 days)

Due to the presence of the magnetically susceptible deoxyhaemoglobin. The T2 relaxationtime will be markedly shortened, so that fresh blood appears hypointense (black) on the T2weighted MRI images. This hypointensity is commonly surrounded by a widerhyperintense area that represents oedema. On the T1 weighted images fresh blood appearsisointense or slightly hyperintense.

Acute hematoma one to three days old are composed mostly of paramagnetic intracellulardeoxyhemoglobin. The deoxyhemoglobin is formed by the dissociation of oxygen fromhemoglobin, a process that begins within several hours. Because the deoxyhemoglobinwithin intact, clotted hypoxic red blood cells does not cause T1 shortening, the hematomawill have normal to slightly lower signal on TI-weighted MR images. The concentration ofred blood cells with clot and the concentration of fibrin cause T2 shortening, with areas ofvery low signal on T2-weighted spin echo and T2 * -weighted gradient echo images 3.

Figure 13. A 62-year-old female withhypertension presented with acute-onset ataxia and confusion.Noncontrast CT exam of the head [leftimage] showed a large, right cerebellarhemorrhage, which was evacuated torelieve the mass effect on the brainstemand fourth ventricle. The cerebellarhemorrhage is seen hypointense on theT2 image due to Deoxyhemoglobin[right image].

Figure 14. The concentration of red blood cells withclot and the concentration of fibrin cause T2shortening, with areas of very low signal on T2-weighted spin echo and T2 * -weighted gradient echoimages

o The subacute stage (3 days - one month)

The picture of hematoma is determined by the oxidation of deoxyhemoglobin tomethemoglobin and its shift from the intracellular to the extracellular compartment. Thepicture of haematoma, during this period is governed by the progressive reduction in theconcentration of deoxyhaemoglobin and the progressive increase in the concentration ofthe oxidized methemoglobin. These changes take place from the periphery of thehaematoma to its center. Intracellular oxidized methemoglobin induces shorting of T2

relaxation time while extracellular oxidized methemoglobin induces prolongation of T2relaxation time

Progressive reduction in the concentration of deoxyhaemoglobin and shift of oxidizedmethemoglobin from the intracellular to the extracellular compartment, due to lyse ofRBCs, results in progressive disappearance of the T2 hypointensity observed in the acutestage. Absence of the deoxyhaemoglobin and appearance extracellular oxidizedmethemoglobin will result in progressive prolongation of the T2 relaxation time that startsfrom the periphery of the haematoma to its center, this results in progressive increase ofthe T2 signal intensity (it becomes brighter); At first the periphery of the haematomabecomes brighter on the T2 weighted images, and this brightness progressively extends tothe center.

Within a few days, the subacute hematoma start to undergo liquefaction with developmentof vasogenic edema. As the edema increases over the first week, it may be great enough tocause herniation. The edema has fluid or water characteristics: iso- to hypointense on TI-weighted images, and hyperintense on T2-weighted images. With oxidation ofdeoxyhemoglobin to strongly paramagnetic intracellular methemoglobin, proton-electrondipole-dipole interactions between hydrogen atoms and the paramagnetic centers ofmethemoglobin will cause marked TI shortening and very high signal intensity on TI-weighted images 4 within the periphery of the hematoma. The intracellular methemoglobinwill cause T2 shortening and very low signal on T2-weighted images.

After erythrocyte membrane breakdown and extracellular migration of methemoglobin,there is neovascularization with removal of blood components and debris by macrophages.The new blood vessels at the periphery of the lesion lack the tight endothelial junctions ofan intact blood brain barrier, and so there is intense enhancement of the margins on bothcontrast CT and MR 1. The fragile granulation tissue vessels predispose the patient toadditional episodes of acute hemorrhage. CT will show a decrease in the density of thehemorrhage and decrease in the mass effect, the latter due to a decrease in edema. MR willexhibit the persistent high signal of extracellular methemoglobin on TI - and T2-weightedimages 4 for up to a year. The peripheral rim of hemosiderin and ferritin has slightly lowsignal on Tl- and marked low signal on T2-weighted images [201 from the susceptibilityeffect of hemosiderin within macrophage lysosomes.

Figure 15. MRI T2 image (A) and proton density image (B) showing a subacutehaematoma, notice the peripheral hypointense hemosiderin ring

Because the extracellular oxidized methemoglobin has a paramagnetic quality it results inshortening of the T1 relaxation time, so that the haematoma in the subacute stage appearshyperintense (bright) on the T1 weighted MRI images. This again starts from the peripheryof the haematoma and progresses to its center, because as mentioned beforemethemoglobin starts to appear at the periphery of the haematoma, this results initially inring hyperintensity on the T1 images.

Figure 16. Early subacute hemorrhagic contusion in a 78-year- old male. Sagittal TI-weighted image demonstrates high signal intensity at the periphery of the hematoma,consistent with extracellular methemoglobin.

The haemosiderin pigmentation that surrounds thehaematoma in the subacute and chronic stages isresponsible for the rim of hypointensity that surrounds thehaematoma on the T2 weighted and proton density images.

Figure 17. The hypointense hemosiderin ring of subacutehaematoma

o Chronic stage (one month to 3 months)

Due to complete absorption of the deoxyhaemoglobin and diffuse and homogeneousincrease of the oxidized methemoglobin within the haematoma; it appears diffuselyhyperintense (bright) on both the T1 and T2 weighted images.

Clot resorption begins from the periphery inward, and depending on the size of thehematoma, may vary from one to six weeks in duration. Necrotic tissue is sloughed andcystic cavities are formed over the next 6 to 12 months. Focal atrophy is characterized by adecrease in the size of cortical gyri, with compensatory enlargement of cerebrospinal fluidspaces and dilatation of the adjacent ventricle. Cystic cavities are surrounded by gliosis andhemosiderin scarring.

The hematomabiochemicalstages

Table 1. The MRI biochemical stages of cerebral hematomas

Biochemical substance MRI changesOxyhemoglobin Oxyhemoglobin lacks unpaired electrons and thus clot signal

is close to normal brain parenchyma- normal to slightlylower signal on TI-weighted images and slightly higher signalon T2-weighted images

Paramagnetic intracellulardeoxyhemoglobin.

Because the deoxyhemoglobin within intact, clotted hypoxicred blood cells does not cause T1 shortening, the hematomawill have normal to slightly lower signal on TI-weighted MRimages. The concentration of red blood cells with clot and theconcentration of fibrin cause T2 shortening, with areas ofvery low signal on T2-weighted spin echo and T2 * -weightedgradient echo images

Paramagnetic intracellularmethemoglobin.

Proton-electron dipole-dipole interactions between hydrogenatoms and the paramagnetic centers of methemoglobin willcause marked TI shortening and very high signal intensity onTI-weighted images within the periphery of the hematoma.

The intracellular methemoglobin will cause T2 shorteningand very low signal on T2-weighted images.

Extracellular migration ofmethemoglobin.

MR will exhibit the persistent high signal of extracellularmethemoglobin on TI - and T2-weighted images for up to ayear. The peripheral rim of hemosiderin and ferritin hasslightly low signal on Tl- and marked low signal on T2-weighted images [20] from the susceptibility effect ofhemosiderin within macrophage lysosomes.

Clot resorption begins fromthe periphery inward, anddepending on the size of thehematoma, may vary fromone to six weeks in duration.Necrotic tissue is sloughedand cystic cavities areformed over the next 6 to 12months.

Focal atrophy is characterized by a decrease in the size ofcortical gyri, with compensatory enlargement ofcerebrospinal fluid spaces and dilatation of the adjacentventricle. Cystic cavities are surrounded by gliosis andhemosiderin scarring.

SUMMARY

Table 2. The biochemical stages of cerebral hematomas

Hyperacute stage[0-12 Hr]

Immediately after an intracerebral bleed, the liquefied mass in thebrain substance contains oxyhemoglobin but no paramagneticsubstances. Therefore, it looks like any other proteinaceous fluidcollection.

Acute stage [4Hr -3days]

Reduction in oxygen tension in the hematoma results in the formationof intracellular deoxyhemolobin and methemoglobin in intact redcells. These substances have a paramagnetic effect that produces T2shortening. A thin rim of increased signal surrounding the hematomaon T2-weighted images represents edema.

Subacute stage[3days-3 weeks]

As red blood cells lyse, redistribution of methemoglobin into theextracellular space changes the effect of this paramagnetic substanceto one of predominantly T1 shortening. The longer T2 results from(1)a combination of red blood cell lysis (T2 shortening disappears), (2)osmotic effects that draw fluid into the hematoma, and (3) therepetition times (TR) that are in general use for T2-weightedsequences, which are not sufficiently long to eliminate T1 contrasteffects in the image.

Chronic stage[3weeks-3 months]

Phagocytic cells invade the hematoma (starting at the outer rim andworking inward), metabolizing the hemoglobin breakdown productsand storing the iron as superparamagnetic hemosiderin and ferritin.

Table 3. Effect of blood products on the MRI signal

Hyperacute stage [0-12 Hr] Oxyhemoglobin

T1 T2lacks unpaired electrons and thus clot signalis close to normal brain parenchyma- normalto slightly lower signal on TI-weightedimages and slightly higher signal on T2-weighted images

Acute stage [4Hr -3days]

Deoxyhemoglobinwithin intact, clottedhypoxic red blood

No effect

T2 shortening, withareas of very lowsignal on T2-weightedspin echo and T2 * -weighted gradientecho images

Early subacute stage[3days-3 weeks]

Stronglyparamagneticintracellularmethemoglobin,

TI shortening andvery high signalintensity on TI-weighted imageswithin the peripheryof the hematoma

The intracellularmethemoglobin willcause T2 shorteningand very low signalon T2-weightedimages

Late subacute stage[3days-3 weeks]

extracellularmigration ofethemoglobin

MR will exhibit the persistent high signal ofextracellular methemoglobin on TI - and T2-weighted images for up to a year

Chronic stage[3weeks-3 months]

Focal atrophy is characterized by a decrease in the size of corticalgyri, with compensatory enlargement of cerebrospinal fluid spacesand dilatation of the adjacent ventricle. Cystic cavities aresurrounded by gliosis and hemosiderin scarring.

Table 4. Effect of blood products on the MRI signal

Phase Time Hemoglobin T1 T2

Hyperacute <24 hours Oxyhemoglobin(intracellular)

Iso or hypo Hyper

Acute 1-3 days Deoxyhemoglobin(intracellular)

Iso or hypo Hypo

Early subacute >3 days Methemoglobin(intracellular)

Hyper Hypo

Late subacute >7 days Methemoglobin(extracellular)

Hyper Hyper

Chronic >14 days Hemosiderin(extracellular)

Iso or hypo Hypo

CEREBRAL EDEMA ASSOCIATED WITH NONTRAUMATIC CEREBRALHEMORRHAGE

Traditionally, ICH was believed to cause permanent brain injury directly by mass effect.However, the importance of hematoma-induced inflammatory response and edema ascontributors to secondary neuronal damage has since been recognized. 28,29,30

At least three stages of edema development occur after ICH (Table 5). In the first stage, thehemorrhage dissects along the white matter tissue planes, infiltrating areas of intact brain.Within several hours, edema forms after clot retraction by consequent extrusion ofosmotically active plasma proteins into the underlying white matter 28,29. The second stageoccurs during the first 2 days and is characterized by a robust inflammatory response. Inthis stage, ongoing thrombin production activates by the coagulation cascade, complementsystem, and microglia. This attracts polymorphonuclear leukocytes andmonocyte/macrophage cells, leading to up-regulation of numerous immunomediators thatdisrupt the blood-brain barrier and worsen the edema. 28,29,30 A delayed third stage occurssubsequently, when red blood cell lysis leads to hemoglobin-induced neuronal toxicity.28,29,30 Perihematomal edema volume increases by approximately 75% during the first 24hours after spontaneous ICH and has been implicated in the delayed mass effect thatoccurs in the second and third weeks after ICH. 28,29,30

Thrombin is an essential component of the coagulation cascade, which is activated in ICH.In low concentrations thrombin is necessary to achieve hemostasis. However, in highconcentrations, thrombin induces apoptosis and early cytotoxic edema by a direct effect.Furthermore, it can activate the complement cascade and matrix metalloproteinases(MMP) which increase the permeability of the blood brain barrier. 28,29,30

Delayed brain edema has been attributed, at least in part, to iron and hemoglobindegradation. Hemoglobin is metabolized into iron, carbon monoxide, and biliverdin byheme oxygenase. Studies in animal models show that heme oxygenase inhibition attenuatesperihematomal edema and reduces neuronal loss. 28,29,30 Furthermore, intracerebralinfusion of iron causes brain edema and aggravates thrombin-induced brain edema. Inaddition, iron induces lipid peroxidation generating reactive oxygen species (ROS), anddeferoxamine, an iron chelator, has been shown to reduce edema after experimental ICH.28,29,30

Table 5. Stages of edema after ICH

First stage (hours) Second stage (within first 2 days) Third stage (after first 2days)

Clot retraction andextrusion ofosmotically activeproteins

Activation of thecoagulation cascade andthrombin synthesis

Complement activation Perihematomal

inflammation and leukocyteinfiltration

Hemoglobin inducedneuronal toxicity

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