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

○ 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

• 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

(Left) Axial graphic shows the

evolution of parenchymal

hemorrhage from hyperacute

﬈ (intracellular oxy-Hgb) to

acute ſt (intracellular deoxyHgb with surrounding edema) .

Early ﬊ and late subacute

(intra- and extracellular metHgb, respectively) are

followed by a chronic cystic

cavity ﬉ with a hemosiderin

stain. (Right) Axial NECT

shows a hyperdense mass

related to an acute left

cerebellar hemorrhage ſt

with minimal surrounding

edema in a patient with

hypertension.

(Left) Axial T1WI MR in the

same patient shows that the

cerebellar hemorrhage ﬇ is

predominantly isointense and

mildly hypointense to the

surrounding brain

parenchyma, indicating

hyperacute blood products.

(Right) Axial T2WI MR in the

same patient shows the

hyperacute hemorrhage to be

hyperintense to the

surrounding brain parenchyma

with a peripheral hypointense

rim st. Intraparenchymal

hemorrhage evolves from

peripheral to central with the

central core maturing more

slowly.

Trauma, and Stroke

Brain: Pathology-Based Diagnoses: Malformations,

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