Spontaneous Nontraumatic Intracranial Hemorrhage

KEY FACTS

TERMINOLOGY

• Primary intraparenchymal hemorrhage (pICH)

• Acute nontraumatic intracranial hemorrhage (ICH)

IMAGING

• Acute round or oval intracerebral hematoma

• Subcentimeter "microbleeds" to massive ICH

• Hematoma location for common causes of pICH

○ HTN: Basal ganglia > thalamus > pons > cerebellum

○ Amyloid angiopathy: Lobar

○ Arteriovenous malformation: Any location

○ Cavernous malformation: Any location

○ Venous sinus thrombosis: Subcortical white matter

○ Neoplasm: Any location

• Recommended imaging: Begin with NECT

○ If HTN with striatocapsular hematoma → stop

○ If atypical hematoma  → CTA or MR/MRA

○ Atypical hematoma or unclear history: MR (T2*, DWI, C+)

○ If standard study suggests vascular etiology → CTA/MRA

○ If concern for venous infarct → CTV/MRV

PATHOLOGY

• Pediatric patients, < 18 years old: Vascular malformation (~

50%) > hematologic disorders, vasculopathy, venous

infarct, neoplasm

• Young adults, < 45 years old: Vascular malformation, drug

abuse, venous thrombosis, PRES, vasculitis, neoplasm

• Adults > 45 years old: HTN, amyloid > neoplasm (primary or

metastatic), venous infarct, coagulopathy

CLINICAL ISSUES

• ICH causes ~ 15% of acute strokes

• Treatment: Control of intracranial pressure, hydrocephalus

• Surgical evacuation when clinically indicated

• If positive spot sign indicates active bleeding, predicts

hematoma expansion and poor outcome

• 1-year mortality approaches 60%

(Left) Axial NECT in an elderly

hypertensive patient shows a

hyperdense hematoma

centered in the left external

capsule and putamen ﬇ with

intraventricular extension of

hemorrhage st. This is the

most common location for a

hypertensive hemorrhage.

(Right) Axial CT in this 5 year

old shows a large frontal lobe

hemorrhage ﬇ with

surrounding edema and mass

effect. Additional imaging

revealed an underlying

cavernous malformation. In

children, vascular lesions

represent ~ 50% of all

intracranial hemorrhages.

(Left) Axial NECT in a 73-yearold hypertensive

anticoagulated man with

sudden onset of right

hemiparesis shows a mixeddensity hematoma centered in

the lateral putamen/external

capsule ſt. (Right) CTA in the

same case shows 2 enhancing

foci (spot sign) ﬇ within the

clot, which also is expanding

ſt and demonstrates a fluidfluid level st. All are dire

prognostic indicators. The

patient expired shortly after

the scan was obtained.

Brain: Pathology-Based Diagnoses: Malformations,

Trauma, and Stroke

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