Eric Swart MS3Gillian Lieberman, MD

Intracranial Hemorrhage and Sequelae

Eric Swart, Harvard Medical School Year III Gillian Lieberman, MD

January 2007

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Eric Swart MS3Gillian Lieberman, MD

Agenda

• Patient Presentation

• Brief review of neuroanatomy

• Causes of hemorrhage and radiologic appearance

• Imaging principles of blood

• Physiology and consequences of hemorrhage

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Eric Swart MS3Gillian Lieberman, MD

Patient 1• 83 y/o M with IDDM, CAD, and CRI presents

s/p fall in home with RU extremity redness.

• Further history reveals multiple minor falls over past month associated with dizziness and minor head trauma.

• Current medications include ASA

• Any imaging?

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Eric Swart MS3Gillian Lieberman, MD

Our Patient: Admission CT

Courtesy of Dr. Handwerker

Axial CT of head, initially read as “normal”

Lesion on falx?

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Eric Swart MS3Gillian Lieberman, MD

Our Patient: Head CT Hospital Day 3

Courtesy of Dr. Handwerker

Pt found unresponsive in a.m.

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Eric Swart MS3Gillian Lieberman, MD

Our Patient: Subdural Hematoma

Layering Hemorrhage

Possible Subarachnoid Compression

of ventricles

Midline shift

Courtesy of Dr. Handwerker

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Eric Swart MS3Gillian Lieberman, MD

Anatomy Review

http://www.surgery.ucsf.edu

Epidural Subdural Intraparenchymal

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 1: Epidural Hematoma on CT• Usually due to trauma

(deceleration) • Brief lucid interval• Laceration of the

meningeal arteries (although can be venous!)

• “Lentiform”• Does not cross sutures

http://www.muhealth.org/~neuromed/

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 2: Epidural Hematoma on CT

Courtesy of Dr. Handwerker

Hematoma

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 2: Cranial Fracture on CT

Courtesy of Dr. Handwerker

Fracture

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 4: Subdural Hematoma on CT

• Usually due to trauma (shearing)

• Gradual onset of sx• Tears in the small

bridging veins• Crescent-shaped• Can cross sutures, but not

midline

http://www.sbhemresidency.com/

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 5: Subdural Hematoma?

Courtesy of Dr. Handwerker

Hypodense lesion, possible chronic bleed?

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 5: Subdural Hematoma?

Courtesy of Dr. Handwerker

Axial Diffusion Weighted MRI

Hyperintense lesion in subdural space

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 5: Subdural Empyema

Courtesy of Dr. Handwerker

Coronal T1 MRI Post-Contrast

Hyperintense lesion in subdural space and in sinuses, found to be pus at surgery.

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 6: Subarachnoid Hemorrhage on CT

• Causes include traumatic, aneurysm, AVM, tumor.

• Same space as intraventricular hem.

• “Worst headache ever”• “Star pattern”

http://www.emedicine.com/Courtesy of Dr. Handwerker

Blood in Suprasellar Sulcus

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 7: Traumatic Subarachnoid Hemorrhage on CT

http://www.uth.tmc.edu/radiology/

Peripheral blood in sulci

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 8: MCA Aneurysm• Common locations:

– Anterior communicating– MCA– Posterior communicating– Basilar

Courtesy of Dr. Handwerker

Axial CTA

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 9:Non-Aneurysmal Bleed (Perimesencephalic Hemorrhage)

Courtesy of Dr. Handwerker

Blood in interpeduncular fossa Blood peripheral to

midbrain

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 10:Intraparenchymal Hemorrhage on CT

• Causes include traumatic, CVA, HTN, tumor, coagulopathy, AVM.

• Commonly involve basal ganglia, thalamus, pons, and cerebellum

• Round or irregular lesions

http://www.uhrad.com

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Eric Swart MS3Gillian Lieberman, MD

Diffuse Axonal Injury• Results from shearing trauma• Diffuse, bilateral injury at the grey-white matter

junction• CT: multiple small intraparenchymal hem.• MRI may be more sensitive

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Eric Swart MS3Gillian Lieberman, MD

Courtesy of Dr. Kang

Companion Pt 11: Diffuse Axonal Injury on CT

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Eric Swart MS3Gillian Lieberman, MD

30 Days in the Life of a Hemorrhage• Five distinct stages of a intracranial hemorrhage:

– Hyperacute: <12 hours– Acute: 12 h – 2 days– Early subacute: 2 – 7 days– Late subacute: 8 days – 1 month– Chronic >1 month – years

• Imaging principles:– Clot density changes dominate on CT– Changes in hemoglobin dominate on MR

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Eric Swart MS3Gillian Lieberman, MD

CT Appearance of Aging Hemorrhage• Clot is initially liquid mix of RBC’s, WBC’s,

platelets, and serum.– hyperacute = isointense

• As the clot contracts, the core becomes denser while the surrounding areas become edematous. – acute – early subacute = hyperintense

• Over time, the clot degrades, and the edema subsides.– late subacute – chronic = isointense-hypointense,

may enhance with contrast due to BBB breakdown

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Eric Swart MS3Gillian Lieberman, MD

MRI Appearance of Aging in HemorrhageTime Iron Magnetic Status

Hyperacute Intracellular oxygenated hemoglobin Diamagnetic

Acute Intracellular deoxygenated hemoglobin Paramagnetic

Early Subacute Intracellular methemoglobin Paramagnetic

Late Subacute Extracellular methmoglobin Paramagnetic

Chronic Hemosiderin and ferritin in macrophages Superparmagnetic

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Eric Swart MS3Gillian Lieberman, MD

Summary: Appearance of Hemorrhage on CT and MRI

Time CT MR T1 MR T2

Hyperacute:< 12 hours – – ↑

Acute:12 h – 2 days ↑ – ↓

Early subacute:2 – 7 days ↑ ↑ ↓

Late subacute:8 days – 1 month – ↑ ↑

Chronic:>1 month – years –

↓ ↓ ↑

= Hyperintense = Isointense = Hypointense

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Eric Swart MS3Gillian Lieberman, MD

Herniation

http://uptodate.com

http://www.uth.tmc.edu/radiology/

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Eric Swart MS3Gillian Lieberman, MD

Anatomy Review Part 2

http://biocfarm.unibo.it/

Tentorium

Falx

(Note the proximity of critical brainstem and cranial nerve structures)

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 12: Subfalcine Herniation on CT

• Singulate gyrus on medial aspect of frontal lobe is displaced across the midline across the free edge of the falx

• May compromise ACA flow

http://www.emedicine.com

Midline shift of singulate gyrus under falx

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Eric Swart MS3Gillian Lieberman, MD

Transtentorial Herniation• Medial aspect of temporal lobe (uncus) migrates

across tentorium• Causes 3rd nerve compression• Can also be ascending herniation, most often

from tumor in posterior fossa

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Eric Swart MS3Gillian Lieberman, MD

Companion Patients 13 and 14: Transtentorial Herniation on CT

http://www.geocities.com/drweightlosshttp://rad.usuhs.mil/rad/herniation/

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Eric Swart MS3Gillian Lieberman, MD

Central Herniation• Diffuse increase in ICP displaces each cerebral

hemisphere downward through tentorium• Compresses upper brainstem

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 15: Tonsilar Herniation on MRI

• Increased pressure develops in the posterior fossa, displacing cerebellar tonsils downward through the foramen magnum

• Compresses lower brainstem and upper cervical cord

http://www.kem.edu/dept/radiology/Cerebellar tonsils herniating through foramen magnum

Lesion (flow artifact indicates likely aneurysmal)

Sagital T1 MRI

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Eric Swart MS3Gillian Lieberman, MD

Companion Pt 16: Extracranial Hernation on CT

http://www.emedicine.com/

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Eric Swart MS3Gillian Lieberman, MD

Summary• Intracranial hemorrhage is defined by its

location with respect to the meninges– Trauma is usually the most common cause

• Hemorrhage undergoes a predictable temporal sequence of changes that can be seen on MR and CT and used to estimate the age of the bleed.

• An increase in mass can cause increased ICP and can result in extremely dangerous herniations.– Dural reflections are commonly involved

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Eric Swart MS3Gillian Lieberman, MD

AcknowledgementsThanks to:• Gillian Lieberman, MD• Jason Handwerker, MD• James Kang, MD• Pamela Lepkowski• Larry Barbaras

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Eric Swart MS3Gillian Lieberman, MD References

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European Radiology 2005; 15:434-440.

• Parizel

PM, Makkat

S, Van Miert

E, van Goethem

JW, van den Hauwe

L, De Schepper

AM. Intracranial hemorrhage: principles of CT and MRI interpretation. European Radiology 2001; 11:1770-1783

• Ruigrok, YM, Rinkel, GJ, Buskens, E, et al. Perimesencephalic

hemorrhage and CT angiography: A decision analysis. Stroke 2000; 31:2976.

• Noveline, RA. Squire’s Fundamentals of Radiology 6th

edition. Cambridge, 2004.• Grossman RI, Yousem

DM. Neuroradiology: The Requisites 2nd

edition. 2003.• Nolte, J. The Human Brain: An Introduction to Its Functional Anatomy 5th

edition. 2002.• Moore, KL, Daley, AF. Clinically Oriented Anatomy 4th

edition. 1999.• http://uptodate.com• http://www.surgery.ucsf.edu• http://www.muhealth.org/~neuromed/• http://www.sbhemresidency.com/• http://www.uth.tmc.edu/radiology/• http://emedicine.com• http://www.uhrad.com• http://biocfarm.unibo.it/• http://rad.usuhs.mil/rad/herniation/• http://www.geocities.com/drweightloss• http://www.kem.edu/dept/radiology/