Short case publication... version 1.10 | Edited by professor Yasser Metwally | February 2008
Professor Yasser Metwally
Professor of neurology
Ain Shams university school of medicine
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A 64 years old female patients presented clinically with sudden onset of right hemiplegia and global aphasia.
DIAGNOSIS: HYPERTENSIVE PUTAMENO-CAPSULAR HEMORRHAGE
Figure 1. Late subacute hematoma. A CT scan image showing the hematoma as an oval hyperdense space
occupying lesion with positive mass effect. The lesion is surrounded by a hypodense edema rim. The increased
protein content of the retracted clot is responsible for the high attenuation noted on noncontrast CT. B,C
precontrast MRI T1 images. The subacute hematoma has a hyperintense peripheral rim (due to extracellular
methemoglobin) and a central isointensity mostly due to Paramagnetic intracellular deoxyhemoglobin.
Figure 2. Late subacute hematoma. MRI T2 images. The subacute hematoma has a hyperintense peripheral rim
(due to extracellular methemoglobin) and a central hypointensity mostly due to Paramagnetic intracellular
deoxyhemoglobin. Edema could also contribute to the peripheral T2 hyperintensity.
Figure 3. Late subacute hematoma. MRI FLAIR images. The subacute hematoma has a hyperintense peripheral
rim (due to extracellular methemoglobin) and a central iso to hypointensity mostly due to deoxyhemoglobin. In this
patient the appearance of the subacute hematoma on FLAIR images is similar to that seen on MRI T2 images.
Edema could also contribute to the peripheral T2 hyperintensity.
Figure 4. Diffusion weighted images. The appearance of hemorrhage on DW MR images is complex and involves
many factors, including the relative amounts of different hemorrhagic products and the pulse sequence used.
Oxyhemoglobin is hyperintense on DW images and has a lower ADC than does normal brain tissue; this may
indicate the relative restriction of water movement inside the red blood cell (101). Extracellular methemoglobin
has a higher ADC than does normal brain tissue, which indicates that the mobility of water in the extracellular
space is increased. The prolongation of the T2 component of fluid with extracellular methemoglobin results in
hyperintensity on DW images. Hemorrhage containing deoxyhemoglobin, intracellular methemoglobin, and
hemosiderin are hypointense on DW images because of magnetic susceptibility effects. Because these products of
hemorrhage have very low signal intensity on T2-weighted images, ADCs cannot be reliably calculated for them.
Figure 5. For comparison, A view showing the hematoma on CT scan, precontrast MRI T1 image, MRI T2,
FLAIR and diffusion weighted images.
The hematoma biochemical stages
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1. Metwally, MYM: Textbook of neurimaging, A CD-ROM publication, (Metwally, MYM editor) WEB-CD agency for
electronic publishing, version 9.1a January 2008