Evolution of Intracranial Hemorrhage

KEY FACTS

Imaging

• CT: Hemorrhage appearance based on density

  • Hyperdense mass (50-70 Hounsfield units) on NECT

  • Peripheral edema develops over 1st few days

• MR: Intracranial hemorrhage staging based on T1 and T2 signal characteristics

  • MR as sensitive as CT in hyperacute phase; more sensitive in subacute/chronic phases

  • Hematoma matures more slowly in center (core) than in periphery

    • –

      Therefore MR signal change proceeds peripherally to centrally

Pathology

• Very common: Hypertension (HTN), cerebral amyloid angiopathy, trauma, hemorrhagic vascular malformations

• Common: Infarct with reperfusion, coagulopathy, blood dyscrasia, drug abuse, tumor (glioma, metastases)

Clinical Issues

• Incidence: ~ 30-40 per 100,000

• HTN, ↑ age most important risk factor

  • Rate of anticoagulant-related intracerebral hematoma (ICH) has increased over last decades (up to 20%)

  • ICH with warfarin = higher mortality (2x at 3 months)

• Common signs, symptoms

  • HTN (90%), vomiting (50%), ↓ consciousness (50%), headache (40%), seizures (10%)

• Prognosis depends on size, initial level of consciousness, location

  • 35-52% dead at 1 month (50% of whom died in first 2 days); 59% dead at 1 year

  • Large hematoma (> 30 mL), swirl sign on NECT → higher mortality

  • Active contrast extravasation → higher mortality

Diagnostic Checklist

• Marked heterogeneity of acute hematoma on CT predicts hematoma growth and ↑ mortality

• Swirl sign, contrast extravasation enhancement indicate hematoma growth and ↑ mortality

• Fluid-fluid levels → question of underlying coagulopathy

TERMINOLOGY

IMAGING