hemorrhage

associated with a
right frontal
arteriovenous
malformation.Intr
acranial
hemorrhage.
Fluid-attenuated
inversion-
recovery, T2-
weighted, and
gradient echo
MRI depiction of
left temporal
intracranialhemor
rhage due to
sickle cell
disease.
o

AVMs and
cavernous
angiomas may be
identified by the
presence
of multiple flow
voidsadjacent to
the hematoma.
o

Paramagnetic
contrast may be
injected
to increase
screening yield
for underlying
tumoror vascular
malformation.
o

Gradient echo
sequences may
reveal multiple
foci of
hypointensity
attributable
tohemosiderin
deposition from
prior silent
cerebral
microbleeds. A
multilobar
distributionof
hypointense foci
on gradient echo
imaging may
provide
supportive
evidence
of cerebral
amyloid
angiopathy, while
multiple deep foci
may suggest an
underlyinghyperte
nsive
arteriopathy.
o
MRI studies
incorporating
gradient echo or
susceptibility-
weighted
sequences may
beused as the
sole imaging
modality for
patients with
acute stroke,
readily
identifyingintracr
anial hemorrhage.
o
Permeability
techniques,
including use of
source perfusion
imaging data, may
be used todetect
blood-brain
derangements
that precede
hemorrhagic
transformation
afterthrombolysi
s.
[6]

This MRI reveals

petechialintracer
ebral hemorrhage
(ICH) due to
cerebral venous
thrombosis.This
MRI reveals
hemorrhagic
transformation of
anischemic infarc
t. This CT scan an
d MRI revealedmi
dbrain
intracerebral
hemorrhage (ICH)
and
intraventricular
hemorrhage
(IVH)associated
with a cavernous
angioma.
Table 1. MRI
Appearance
of Intracerebral
Hemorrhage (Ope
n Table in a new
window)
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
Hyper

Hypo

Late subacute

>7 days
Methemoglobin
(extracellular)

Hyper

Hyper
Chronic

>14 days

Hemosiderin
(extracellular)

Iso or hypo
Hypo

Vessel imaging
o
CT angiography
permits screening
of large and
medium-sized
vessels
for AVMs,vasculit
is, and other
arteriopathies.
o
MR angiography
permits screening
of large and
medium-sized
vessels
for AVMs,vasculit
is, and other
arteriopathies.
o

Conventional
catheter
angiography
definitively
assesses large,
medium-sized,
andsizable small
vessels for AVMs,
vasculitis, and
other
arteriopathies.
o
Consider catheter
angiography for
young patients,
patients with
lobar
hemorrhage,patie
nts without a
history of
hypertension, and
patients without a
clear
cause of hemorrh
age who are
surgical
candidates.
Angiography may
be deferred for
olderpatients
with suspected
hypertensive
intracerebral
hemorrhage and
patients who
donot have any
structural
abnormalities on
CT scan or MRI.
o

Timing of
angiography
depends
on clinical status
and neurosurgical
considerations.
Other Tests
ECG frequently
identifies
cerebrum-induced
dysrhythmia or
cardiac injury.
Procedures
Lumbar
puncture in the
setting of IVH
may reveal
xanthochromia
and a biochemical
profilesimilar to
that observed in
subarachnoid
hemorrhage.

Ventriculostomy
allows for
external
ventricular
drainage in
patients with
intraventricularex
tension of blood
products.
Intraventricular
administration of
thrombolytics
may assist
clotremoval.

Endoscopic
hematoma
evacuation may be
a promising ultra-
early stage
treatment
forintracerebral
hemorrhage that
improves long-
term prognosis.
[7]
Histologic
Findings
Gross examination
reveals focal
accumulation of
blood with
adjacent
destruction
of parenchyma.

Microscopically,
bleeding sites
appear as round
collections of
platelets
surrounded by
fibrin.

Charcot-Bouchard
microaneurysms
may be seen at
bifurcations of
distal lateral
lenticulostriateve
ssels in
hypertensive
intracerebral
hemorrhage.
Lobar
hemorrhages of
cerebral amyloid
angiopathy may
reveal
pathological
deposition of
beta-amyloid
protein within the
media of small
cortical and
meningeal vessels.
Staging
Table 2. Grading
of Subependymal
Hemorrhage(Open
Table in a new
window)

Grade

Hemorrhage
Location
I

Subependymal
hemorrhage

II
Intraventricular
hemorrhage
without
ventriculomegaly

III
Intraventricular
hemorrhage with
ventriculomegaly

IV

Intraventricular
hemorrhage with
parenchymal
hemorrhage