A Pictorial Review of Intracranial Haemorrhage Revisited

Author(s): Andrew Martin*, George Tse, Daniel James Anthony Connolly, Ruth Batty

Journal Name: Current Medical Imaging
Formerly: Current Medical Imaging Reviews

Volume 15 , Issue 9 , 2019

Become EABM
Become Reviewer

Graphical Abstract:


Background: The many causes of Intracerebral Haemorrhage (IH) can be difficult to differentiate. However, there are imaging features that can provide useful clues. This paper aims to provide a pictorial review of the common causes of IH, to identify some distinguishing diagnostic features and to provide guidance on subsequent imaging and follow up. It is hoped that this review would benefit radiology and non-radiology consultants, multi-professional workers and trainees who are commonly exposed to unenhanced CT head studies but are not neuroradiology specialists.

Discussion: In the absence of trauma, Spontaneous Intracerebral Haemorrhage (SIH) can be classified as idiopathic or secondary. Secondary causes of IH include hypertension and amyloid angiopathy (75-80%) and less common pathologies such as vascular malformations (arteriovenous malformations, aneurysms and cavernomas), malignancy , venous sinus thrombosis and infection. SIH causes between 10 to 15% of all strokes and has a higher mortality than ischaemic stroke. Trauma is another cause of IH with significant mortality and some of the radiological features will be reviewed.

Conclusion: Unenhanced CT is a mainstay of acute phase imaging due to its availability and, sensitivity and specificity for detecting acute haemorrhage. Several imaging features can be identified on CT and, along with clinical information, can provide some certainty in diagnosis. For those suitable and where diagnostic uncertainty remains CT angiogram, time-resolved CT angiography and catheter angiography can help identify underlying AVMs, aneurysms, cavernomas and vasculitides. MRI is more sensitive for the detection of subacute and chronic haemorrhage and identification of underlying mass lesions.

Keywords: Intracerebral haemorrhage, amyloid angiopathy, hypertensive haemorrhage, vasculitis, venous sinus thrombosis, herpes encephalitis, vascular malformations.

Fewel ME, Thompson BG, Hoff JT. Spontaneous intracerebral hemorrhage: a review. Neurosurg Focus 2003; 15(4): 1-16.
[http://dx.doi.org/10.3171/foc.2003.15.4.0] [PMID: 15344894]
Samarasekera N, Smith C, Al-Shahi Salman R. The association between cerebral amyloid angiopathy and intracerebral haemorrhage: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2012; 83(3): 275-81.
[http://dx.doi.org/10.1136/jnnp-2011-300371] [PMID: 22056966]
Rensink AA, de Waal RM, Kremer B, Verbeek MM. Pathogenesis of cerebral amyloid angiopathy. Brain Res Brain Res Rev 2003; 43(2): 207-23.
[http://dx.doi.org/10.1016/j.brainresrev.2003.08.001] [PMID: 14572915]
Patel DV, Hier DB, Thomas CM, Hemmati M. Intracerebral hemorrhage secondary to cerebral amyloid angiopathy. Radiology 1984; 151(2): 397-400.
[http://dx.doi.org/10.1148/radiology.151.2.6709910] [PMID: 6709910]
Yamada M, Tsukagoshi H, Otomo E, Hayakawa M. Cerebral amyloid angiopathy in the aged. J Neurol 1987; 234(6): 371-6.
[http://dx.doi.org/10.1007/BF00314080] [PMID: 3655840]
Miller-Thomas MM, Sipe AL, Benzinger TL, McConathy J, Connolly S, Schwetye KE. Multimodality review of amyloid related disease of the central nervous system. Radiographics 2016; 36(4): 1147-63.
[http://dx.doi.org/10.1148/rg.2016150172] [PMID: 27399239]
Chao CP, Kotsenas AL, Broderick DF. Cerebral amyloid angiopathy: CT and MR imaging findings. Radiographics 2006; 26(5): 1517-31.
[http://dx.doi.org/10.1148/rg.265055090] [PMID: 16973779]
Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, et al. PREDICT/ Sunnybrook ICH CTA study group. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol 2012; 11(4): 307-14.
[http://dx.doi.org/10.1016/S1474-4422(12)70038-8] [PMID: 22405630]
Sutherland GR, Auer RN. Primary intracerebral hemorrhage. J Clin Neurosci 2006; 13(5): 511-7.
[http://dx.doi.org/10.1016/j.jocn.2004.12.012] [PMID: 16769513]
Macellari F, Paciaroni M, Agnelli G, Caso V. Neuroimaging in intracerebral hemorrhage. Stroke 2014; 45(3): 903-8.
[http://dx.doi.org/10.1161/STROKEAHA.113.003701] [PMID: 24425128]
Ondra SL, Troupp H, George ED, Schwab K. The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 1990; 73(3): 387-91.
[http://dx.doi.org/10.3171/jns.1990.73.3.0387] [PMID: 2384776]
Mohr JP, Parides MK, Stapf C, et al. International ARUBA investigators.Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383(9917): 614-21.
[http://dx.doi.org/10.1016/S0140-6736(13)62302-8] [PMID: 24268105]
Broderick JP, Adams HP Jr, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the stroke council, American heart association. Stroke 1999; 30(4): 905-15.
[http://dx.doi.org/10.1161/01.STR.30.4.905] [PMID: 10187901]
Geibprasert S, Pongpech S, Jiarakongmun P, Shroff MM, Armstrong DC, Krings T. Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. Radiographics 2010; 30(2): 483-501.
[http://dx.doi.org/10.1148/rg.302095728] [PMID: 20228330]
Dawkins AA, Evans AL, Wattam J, et al. Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures. Neuroradiology 2007; 49(9): 753-9.
[http://dx.doi.org/10.1007/s00234-007-0252-y] [PMID: 17594083]
Robinson JR, Awad IA, Little JR. Natural history of the cavernous angioma. J Neurosurg 1991; 75(5): 709-14.
[http://dx.doi.org/10.3171/jns.1991.75.5.0709] [PMID: 1919692]
Gross BA, Du R. Hemorrhage from cerebral cavernous malformations: a systematic pooled analysis. J Neurosurg 2017; 126(4): 1079-87.
[http://dx.doi.org/10.3171/2016.3.JNS152419] [PMID: 27203143]
Rivera PP, Willinsky RA, Porter PJ. Intracranial cavernous malformations. Neuroimaging Clin N Am 2003; 13(1): 27-40.
[http://dx.doi.org/10.1016/S1052-5149(02)00060-6] [PMID: 12802939]
Etminan N, Rinkel GJ. Unruptured intracranial aneurysms: development, rupture and preventive management. Nat Rev Neurol 2016; 12(12): 699-713.
[http://dx.doi.org/10.1038/nrneurol.2016.150] [PMID: 27808265]
Thai QA, Raza SM, Pradilla G, Tamargo RJ. Aneurysmal rupture without subarachnoid hemorrhage: case series and literature review. Neurosurgery 2005; 57(2): 225-9.
[http://dx.doi.org/10.1227/01.NEU.0000166535.59056.FA] [PMID: 16094149]
Marder CP, Narla V, Fink JR, Tozer Fink KR. Subarachnoid hemorrhage: beyond aneurysms. AJR Am J Roentgenol 2014; 202(1): 25-37.
[http://dx.doi.org/10.2214/AJR.12.9749] [PMID: 24370126]
Salvarani C, Brown RD Jr, Calamia KT, et al. Primary central nervous system vasculitis: analysis of 101 patients. Ann Neurol 2007; 62(5): 442-51.
[http://dx.doi.org/10.1002/ana.21226] [PMID: 17924545]
Demaerel P, De Ruyter N, Maes F, Velghe B, Wilms G. Magnetic resonance angiography in suspected cerebral vasculitis. Eur Radiol 2004; 14(6): 1005-12.
[http://dx.doi.org/10.1007/s00330-004-2239-y] [PMID: 14872278]
Scott M. Spontaneous intracerebral hematoma caused by cerebral neoplasms. Report of eight verified cases. J Neurosurg 1975; 42(3): 338-42.
[http://dx.doi.org/10.3171/jns.1975.42.3.0338] [PMID: 1167903]
Zimmerman RA, Bilaniuk LT. Computed tomography of acute intratumoral hemorrhage. Radiology 1980; 135(2): 355-9.
[http://dx.doi.org/10.1148/radiology.135.2.7367626] [PMID: 7367626]
Gildersleeve N Jr, Koo AH, McDonald CJ. Metastatic tumor presenting as intracerebral hemorrhage. Radiology 1977; 124: 109-12.
[http://dx.doi.org/10.1148/124.1.109] [PMID: 559323]
Bradley WG. MR appearance of hemorrhage in the brain. Radiology 1993; 189(1): 15-26.
[http://dx.doi.org/10.1148/radiology.189.1.8372185] [PMID: 8372185]
Ilica AT, Rodrigues F, Maluf F, Aygun N. Organizing hematoma mimicking brain tumor. Clin Imaging 2013; 37(1): 143-6.
[http://dx.doi.org/10.1016/j.clinimag.2012.04.006] [PMID: 23206621]
Kamide T, Seki S, Suzuki K, et al. A chronic encapsulated intracerebral hematoma mimicking a brain tumor: findings on arterial spin labeling of MRI. Neuroradiol J 2016; 29(4): 273-6.
[http://dx.doi.org/10.1177/1971400916648334] [PMID: 27154189]
Satoshi N, Tomohisa O, Yoshiki A, et al. Organising intracerebral Hematoma mimicking a recurrent brain tumour on FDG-PET. Clin Nucl Med 2013; 38(11): 411-3.
Tsuruta W, Tsuboi K, Nose T. Serial neuroimaging of encapsulated chronic intracerebral hematoma with repeated hemorrhage-case report. Neurol Med Chir (Tokyo) 2003; 43(9): 439-42.
[http://dx.doi.org/10.2176/nmc.43.439] [PMID: 14560848]
Girot M, Ferro JM, Canhão P, et al. ISCVT Investigators.Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke 2007; 38(2): 337-42.
[http://dx.doi.org/10.1161/01.STR.0000254579.16319.35] [PMID: 17204682]
Tsai FY, Wang AM, Matovich VB, et al. MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol 1995; 16(5): 1021-9.
[PMID: 7639123]
Rodallec MH, Krainik A, Feydy A, et al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics 2006; 26(1): S5-S18.
[http://dx.doi.org/10.1148/rg.26si065505] [PMID: 17050519]
Crombé D, Haven F, Gille M. Isolated deep cerebral venous thrombosis diagnosed on CT and MR imaging. A case study and literature review. JBR-BTR 2003; 86(5): 257-61.
[PMID: 14651078]
Alsafi A, Lakhani A, Carlton Jones L, et al. Cerebral venous sinus thrombosis, a non enhnaced CT diagnosis? Radiol Res Pract 2015; 2015581437
Roland T, Jacobs J, Rappaport A, Vanheste R, Wilms G, Demaerel P. Unenhanced brain CT is useful to decide on further imaging in suspected venous sinus thrombosis. Clin Radiol 2010; 65(1): 34-9.
[http://dx.doi.org/10.1016/j.crad.2009.09.008] [PMID: 20103419]
Black DF, Rad AE, Gray LA, Campeau NG, Kallmes DF. Cerebral venous sinus density on noncontrast CT correlates with hematocrit. AJNR Am J Neuroradiol 2011; 32(7): 1354-7.
[http://dx.doi.org/10.3174/ajnr.A2504] [PMID: 21566009]
Buyck PJ, De Keyzer F, Vanneste D, Wilms G, Thijs V, Demaerel P. CT density measurement and H:H ratio are useful in diagnosing acute cerebral venous sinus thrombosis. AJNR Am J Neuroradiol 2013; 34(8): 1568-72.
[http://dx.doi.org/10.3174/ajnr.A3469] [PMID: 23471024]
Avsenik J, Oblak JP, Popovic KS. Non-contrast computed tomography in the diagnosis of cerebral venous sinus thrombosis. Radiol Oncol 2016; 50(3): 263-8.
[http://dx.doi.org/10.1515/raon-2016-0026] [PMID: 27679541]
Meckel S, Reisinger C, Bremerich J, et al. Cerebral venous thrombosis: diagnostic accuracy of combined, dynamic and static, contrast-enhanced 4D MR venography. AJNR Am J Neuroradiol 2010; 31(3): 527-35.
[http://dx.doi.org/10.3174/ajnr.A1869] [PMID: 19892813]
Gkrania-Klotsas E, Lever AM. Herpes simplex I encephalitis presenting as a brain haemorrhage with normal cerebrospinal fluid analysis: a case report. J Med Case Reports 2008; 2: 387.
[http://dx.doi.org/10.1186/1752-1947-2-387] [PMID: 19091062]
Gnann JW Jr, Whitley RJ. Herpes simplex encephalitis: an update. Curr Infect Dis Rep 2017; 19(3): 13.
[http://dx.doi.org/10.1007/s11908-017-0568-7] [PMID: 28251511]
Takeuchi S, Takasato Y. Herpes simplex virus encephalitis complicated by intracerebral hematoma. Neurol India 2011; 59(4): 594-6.
[http://dx.doi.org/10.4103/0028-3886.84344] [PMID: 21891940]

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2019
Page: [853 - 865]
Pages: 13
DOI: 10.2174/1573405614666180528080436
Price: $65

Article Metrics

PDF: 28
PRC: 1