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Acute non-traumatic intracranial hemorrhage…
Acute Non-traumatic
Intracranial Hemorrhage
imaging approach
Dr Manohar Aribandi MD, DABR
Senior Consultant Radiologist
Teleradiology Solutions
Hyderabad
Acute non-traumatic intracranial hemorrhage…
Acute Non-traumatic
Intracranial Hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal hemorrhage
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Acute severe headache – worst headache of life
• High mortality – 50%; high morbidity
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Diagnosis
• Etiology
• Complications
Radiologist’s role
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Diagnosis
• Etiology
• Complications
• CT is best – 98%
• Hyperdensity in the
Cisterns, sulci, surface
• Subtle SAH
 Interpeduncular
 Perimesencephalic
 Foramen magnum
 Convexity sulci
• Pseudo SAH !
• > 12 hrs – LP (96%)
• MRI - FLAIR
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
FLAIR
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Diagnosis
• Etiology
• Complications
• Aneurysm - 85%
• Nonaneurysmal
perimesencephalic hemg – 10%
• Others – 5%
Acute non-traumatic intracranial hemorrhage…
Aneurysm
• Mild to severe
( Fischer scale 1 -4)
• Basal cisterns
• Localizing value
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Aneurysm
• CTA – 93% (metaanalysis in 2003)
• Quick, accurate, non-invasive
• Thin axials, sagittal and coronal reformatted
images, MIP reformats, 3D
• Common locations – ACom, PCom, MCA,
Basilar tip
• Multiple – 20% (which one has bled?)
Acute non-traumatic intracranial hemorrhage…
Aneurysm
Acute non-traumatic intracranial hemorrhage…
Aneurysm
Rt MCAAneurysm
Acute non-traumatic intracranial hemorrhage…
Aneurysm
ACom PCom
Multiple aneurysms
Acute non-traumatic intracranial hemorrhage…
Aneurysm
Calcification in aneurysms
www.clinicalgate.com
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Other causes
• AVM – mixed IPH + SAH
• Dural AV fistula
• Sinovenous thrombosis
• Nonaneurysmal perimesencephalic
hemorrhage – no cause identified on CTA or
angiography
• Other causes – vasculitis, RCVS
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
IPH + SAH due to AVM
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
IPH + SAH due to AVM
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
SAH due to dural AV fistula
AJR 2014; 202:25–37
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Convexity sulcal SAH
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Convexity sulcal SAH
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Convexity sulcal SAH
Reversible cerebral vasoconstriction syndrome
J Korean Neurosurg Soc. 2014 Nov;56(5):419-422
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Convexity sulcal SAH
• Complications are rare
• Etiology
 Cortical vein thrombosis (CVT)
 Cerebral amyloid angiopathy (CAA)
 Posterior reversible encephalopathy
syndrome (PRES)
 Reversible cerebral vasoconstriction
syndrome – younger patients
 Vasculitis
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
AJNR Am J Neuroradiol 25:1676–1679,
November/December 2004
SAH due to cortical vein thrombosis
Follow up
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Perimesencephalic nonaneurysmal
subarachnoid hemorrhage (pnSAH)
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Perimesencephalic nonaneurysmal
subarachnoid hemorrhage (pnSAH)
• 10 % of all SAH
• Around the pons, midbrain
• CTA negative - Angio negative
• Probably venous bleed
• Benign outcome – no rebleed,
vasospasm, or ischemia
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Pseudo SAH !!
• Meningitis – pyogenic, carcinomatosis
• Diffuse cerebral edema, Global Hypoxia
• Contrast – delayed imaging, intrathecal
• Venous angioma on NCCT
• Cortical vein thrombosis
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
Pseudo SAH !!
3 days prior - NormalDiffuse Hypoxia
AJNR 2003 24: 254-256
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Diagnosis
• Etiology
• Complications
Radiologist’s role
• Hydrocephalus
• Rebleed
• Vasospasm/Ischemia
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Hydrocephalus
• Rebleed
• Vasospasm/Ischemia
Complications
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Hydrocephalus
• Rebleed
• Vasospasm/Ischemia
Complications
J Korean Neurosurg Soc. 2009 Apr;45(4):240-242
Ruptured Lt MCA aneurysm
8 hrs laterInitial CT
Acute non-traumatic intracranial hemorrhage…
Subarachnoid Hemorrhage
• Hydrocephalus
• Rebleed
• Vasospasm/Ischemia
Complications
Martin Barth et al. Stroke. 2007;38:330-336
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
•Diagnosis
•Etiology
•Complications
Radiologist’s Role
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Diagnosis
• CT
• MRI
• acute
• Subacute
• chronic
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Diagnosis
• CT
• MRI
• acute
• Subacute
• chronic
Acute
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Diagnosis
• CT
• MRI
• acute
• Subacute
• chronic
Acute
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Diagnosis
• CT
• MRI
• acute
• Subacute
• chronic
Acute
Chronic
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Acute Hemorrhage??
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Acute Hemorrhage??
1 yr Prior
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Etiology
• Hypertension
• Amyloid angiopathy
• Vascular – AVM, Cav Hemang
• Neoplastic – GBM, Metastases
• Coagulopathy
80% -90%
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
• Basal ganglia
 Elderly - HTN
 Young - Drug abuse
• Lobar
 Elderly - Amyloid, HTN, neoplasm, SVT
 Young – AVM, coagulopathy, SVT
• Gray-white interface
 Metastases, septic emboli, fungal infection
Common causes by Location
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hypertensive hemorrhage
• Lentiform nucleus: 50% - 60%
• Thalamus: 10% - 25%
• Pons: 5% - 10%
• Cerebellum: 5% - 10%
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hypertensive hemorrhage
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Amyloid angiopathy
• Increased incidence with older age
• Lobar hemorrhage: F>P>O>T
• Recurrent hemorrhages – 10% per yr
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Amyloid angiopathy
3 mo later
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Amyloid angiopathy
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
AVM
• Bleeding from the nidus or the proximal portion of
the draining veins
• Hemg - parenchymal, intraventricular, SAH
• NCCT – Hemg, calcification
• CTA/angiography – diagnostic
 can be negative initially (20%)
 repeat angio after clot has resorbed
• High chance of recurrence of hemorrhage
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
12 yr Boy
AVM
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
T1 w FLAIR
Acute non-traumatic intracranial hemorrhage…
Intraventricular Hemorrhage
12 yr Boy
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Aneurysm
• Specific sites
 MCA aneurysm - deep frontal lobe
 ACom aneurysm – gyrus rectus
 dACA – corpus callosum, medial frontal lobe
• NCCT – curvilinear calcification
Acute non-traumatic intracranial hemorrhage…
Aneurysm
Acute non-traumatic intracranial hemorrhage…
Aneurysm
Rt MCAAneurysm
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Cavernous angioma
• Recurrent microscopic hemorrhages
• Enlarge slowly; sometimes catastrophic
• NCCT – slightly hyperdense, no edema
• MRI – diagnostic; hemg of various ages
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Cavernous angioma
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Cavernous angioma
4 yr girl
Seizures
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Cavernous angioma
4 yr girl
Seizures
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Cavernous angioma
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Venous sinus thrombosis
• Predisposing factors – dehydration, local
neoplasm/infection, hypercoagulation,
Polycythemia, drugs (OC pills,
L-Asparaginase, Tamoxifen )
• NCCT – thrombosed sinuses, cortical veins
edema, hemorrhage, venous infarct
• CECT – filling defects
• MRI, MRV
Acute non-traumatic intracranial hemorrhage…
Dural Sinus Thrombosis
10 yr boy
Dehydrated
Seizures
Acute non-traumatic intracranial hemorrhage…
Dural Sinus Thrombosis
10 yr boy
Dehydrated
Seizures
Acute non-traumatic intracranial hemorrhage…
Dural Sinus Thrombosis
10 yr boy
Dehydrated
Seizures
Acute non-traumatic intracranial hemorrhage…
Dural Sinus Thrombosis
10 yr boy
Dehydrated
Seizures
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Neoplasms
• Metastases – melanoma, renal, lung, breast Ca,
chorio carcinoma
• Pituitary adenoma
• Primary tumors – GBM, choroid plexus ca
• NCCT – hemg, edema +++
• CECT – some enhancement
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Neoplasms
Adenocarcinoma
Esophagus
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Neoplasms
Adenocarcinoma
Esophagus
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Coagulopathy
• Anti coagulation therapy
 7 to10 times higher risk at therapeutic levels
 2/3 are IPH; 1/3 are SDH
• Thrombolytic therapy ( STK, UroK, TPA)
 1% -2 % risk for acMI
• Aspirin therapy – slightly increased risk
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Coagulopathy
Post TPA for AcMI
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Coagulopathy
Post TPA for AcMI
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hemorrhagic infarct
• Edema in arterial territory
• Hemorrhage develops later – hours to weeks
• Hemorrhage in the cortical areas
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hemorrhagic infarct
Lt weakness
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hemorrhagic infarct
Infarct 3 weeks prior
Now on Anti-coagulation
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Hemorrhagic infarct
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Drug abuse
• Cocaine – similar to HTN hemg
 Aneurysms and AVMs may also bleed due to HTN surge
• Heroin, Amphetamines, phencyclidine
• Vasculitis like picture with angiography
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
ISRN Neurology, vol. 2013, Article ID 124390, 5 pages, 2013
Acute Thalamic hemorrhage
in a Cocaine user
Acute non-traumatic intracranial hemorrhage…
Multiple Parenchymal hemorrhages of
different ages on MRI
• Elderly
 Chronic hypertension
 Amyloid angiopathy
• Young
 Cavernous angiomas
 Hematologic disorders
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Other causes
• Acute hemorrhagic leukoencephalopathy
• PRES
• Septic emboli
• Mycotic aneurysms
Acute non-traumatic intracranial hemorrhage…
Intraparenchymal Hemorrhage
Complications
• Increased intracranial pressure
• Rebleed
• Edema, Herniation, infarcts
• Intraventricular extension, hydrocephalus
Acute non-traumatic intracranial hemorrhage…
Imaging guidelines
• NCCT – imaging of choice for suspected ICH
• Surgical candidates without known cause – CTA
• Old hypertensive patients – no need for CTA
• Suspected mass/cavernous hemangioma – MRI
• If CTA is not possible – MRA or catheter angiography
Acute non-traumatic intracranial hemorrhage…
Radiologist’s Responsibility
• Diagnose
• Guide further imaging
• Communicate !
Acute non-traumatic intracranial hemorrhage…
Acute Non-traumatic
Intracranial Hemorrhage
imaging approach
Dr Manohar Aribandi MD, DABR
Senior Consultant Radiologist
Teleradiology Solutions
Hyderabad
Thank You
Acute non-traumatic intracranial hemorrhage…
Acute Non-traumatic
Intracranial Hemorrhage
imaging approach
Dr Manohar Aribandi MD, DABR
Senior Consultant Radiologist
Teleradiology Solutions
Hyderabad
Thank You

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Intracranial hemorrhage dr.manohar

  • 1. Acute non-traumatic intracranial hemorrhage… Acute Non-traumatic Intracranial Hemorrhage imaging approach Dr Manohar Aribandi MD, DABR Senior Consultant Radiologist Teleradiology Solutions Hyderabad
  • 2. Acute non-traumatic intracranial hemorrhage… Acute Non-traumatic Intracranial Hemorrhage • Subarachnoid hemorrhage • Intraparenchymal hemorrhage
  • 3. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage
  • 4. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Acute severe headache – worst headache of life • High mortality – 50%; high morbidity
  • 5. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Diagnosis • Etiology • Complications Radiologist’s role
  • 6. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Diagnosis • Etiology • Complications • CT is best – 98% • Hyperdensity in the Cisterns, sulci, surface • Subtle SAH  Interpeduncular  Perimesencephalic  Foramen magnum  Convexity sulci • Pseudo SAH ! • > 12 hrs – LP (96%) • MRI - FLAIR
  • 7. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage FLAIR
  • 8. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Diagnosis • Etiology • Complications • Aneurysm - 85% • Nonaneurysmal perimesencephalic hemg – 10% • Others – 5%
  • 9. Acute non-traumatic intracranial hemorrhage… Aneurysm • Mild to severe ( Fischer scale 1 -4) • Basal cisterns • Localizing value
  • 10. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Aneurysm • CTA – 93% (metaanalysis in 2003) • Quick, accurate, non-invasive • Thin axials, sagittal and coronal reformatted images, MIP reformats, 3D • Common locations – ACom, PCom, MCA, Basilar tip • Multiple – 20% (which one has bled?)
  • 11. Acute non-traumatic intracranial hemorrhage… Aneurysm
  • 12. Acute non-traumatic intracranial hemorrhage… Aneurysm Rt MCAAneurysm
  • 13. Acute non-traumatic intracranial hemorrhage… Aneurysm ACom PCom Multiple aneurysms
  • 14. Acute non-traumatic intracranial hemorrhage… Aneurysm Calcification in aneurysms www.clinicalgate.com
  • 15. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Other causes • AVM – mixed IPH + SAH • Dural AV fistula • Sinovenous thrombosis • Nonaneurysmal perimesencephalic hemorrhage – no cause identified on CTA or angiography • Other causes – vasculitis, RCVS
  • 16. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage IPH + SAH due to AVM
  • 17. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage IPH + SAH due to AVM
  • 18. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage SAH due to dural AV fistula AJR 2014; 202:25–37
  • 19. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Convexity sulcal SAH
  • 20. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Convexity sulcal SAH
  • 21. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Convexity sulcal SAH Reversible cerebral vasoconstriction syndrome J Korean Neurosurg Soc. 2014 Nov;56(5):419-422
  • 22. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Convexity sulcal SAH • Complications are rare • Etiology  Cortical vein thrombosis (CVT)  Cerebral amyloid angiopathy (CAA)  Posterior reversible encephalopathy syndrome (PRES)  Reversible cerebral vasoconstriction syndrome – younger patients  Vasculitis
  • 23. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage AJNR Am J Neuroradiol 25:1676–1679, November/December 2004 SAH due to cortical vein thrombosis Follow up
  • 24. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Perimesencephalic nonaneurysmal subarachnoid hemorrhage (pnSAH)
  • 25. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Perimesencephalic nonaneurysmal subarachnoid hemorrhage (pnSAH) • 10 % of all SAH • Around the pons, midbrain • CTA negative - Angio negative • Probably venous bleed • Benign outcome – no rebleed, vasospasm, or ischemia
  • 26. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Pseudo SAH !! • Meningitis – pyogenic, carcinomatosis • Diffuse cerebral edema, Global Hypoxia • Contrast – delayed imaging, intrathecal • Venous angioma on NCCT • Cortical vein thrombosis
  • 27. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage Pseudo SAH !! 3 days prior - NormalDiffuse Hypoxia AJNR 2003 24: 254-256
  • 28. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Diagnosis • Etiology • Complications Radiologist’s role • Hydrocephalus • Rebleed • Vasospasm/Ischemia
  • 29. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Hydrocephalus • Rebleed • Vasospasm/Ischemia Complications
  • 30. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Hydrocephalus • Rebleed • Vasospasm/Ischemia Complications J Korean Neurosurg Soc. 2009 Apr;45(4):240-242 Ruptured Lt MCA aneurysm 8 hrs laterInitial CT
  • 31. Acute non-traumatic intracranial hemorrhage… Subarachnoid Hemorrhage • Hydrocephalus • Rebleed • Vasospasm/Ischemia Complications Martin Barth et al. Stroke. 2007;38:330-336
  • 32. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage
  • 33. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage •Diagnosis •Etiology •Complications Radiologist’s Role
  • 34. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Diagnosis • CT • MRI • acute • Subacute • chronic
  • 35. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Diagnosis • CT • MRI • acute • Subacute • chronic Acute
  • 36. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Diagnosis • CT • MRI • acute • Subacute • chronic Acute
  • 37. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Diagnosis • CT • MRI • acute • Subacute • chronic Acute Chronic
  • 38. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Acute Hemorrhage??
  • 39. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Acute Hemorrhage?? 1 yr Prior
  • 40. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Etiology • Hypertension • Amyloid angiopathy • Vascular – AVM, Cav Hemang • Neoplastic – GBM, Metastases • Coagulopathy 80% -90%
  • 41. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage • Basal ganglia  Elderly - HTN  Young - Drug abuse • Lobar  Elderly - Amyloid, HTN, neoplasm, SVT  Young – AVM, coagulopathy, SVT • Gray-white interface  Metastases, septic emboli, fungal infection Common causes by Location
  • 42. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hypertensive hemorrhage • Lentiform nucleus: 50% - 60% • Thalamus: 10% - 25% • Pons: 5% - 10% • Cerebellum: 5% - 10%
  • 43. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hypertensive hemorrhage
  • 44. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Amyloid angiopathy • Increased incidence with older age • Lobar hemorrhage: F>P>O>T • Recurrent hemorrhages – 10% per yr
  • 45. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Amyloid angiopathy 3 mo later
  • 46. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Amyloid angiopathy
  • 47. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage AVM • Bleeding from the nidus or the proximal portion of the draining veins • Hemg - parenchymal, intraventricular, SAH • NCCT – Hemg, calcification • CTA/angiography – diagnostic  can be negative initially (20%)  repeat angio after clot has resorbed • High chance of recurrence of hemorrhage
  • 48. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage 12 yr Boy AVM
  • 49. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage T1 w FLAIR
  • 50. Acute non-traumatic intracranial hemorrhage… Intraventricular Hemorrhage 12 yr Boy
  • 51. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Aneurysm • Specific sites  MCA aneurysm - deep frontal lobe  ACom aneurysm – gyrus rectus  dACA – corpus callosum, medial frontal lobe • NCCT – curvilinear calcification
  • 52. Acute non-traumatic intracranial hemorrhage… Aneurysm
  • 53. Acute non-traumatic intracranial hemorrhage… Aneurysm Rt MCAAneurysm
  • 54. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Cavernous angioma • Recurrent microscopic hemorrhages • Enlarge slowly; sometimes catastrophic • NCCT – slightly hyperdense, no edema • MRI – diagnostic; hemg of various ages
  • 55. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Cavernous angioma
  • 56. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Cavernous angioma 4 yr girl Seizures
  • 57. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Cavernous angioma 4 yr girl Seizures
  • 58. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Cavernous angioma
  • 59. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Venous sinus thrombosis • Predisposing factors – dehydration, local neoplasm/infection, hypercoagulation, Polycythemia, drugs (OC pills, L-Asparaginase, Tamoxifen ) • NCCT – thrombosed sinuses, cortical veins edema, hemorrhage, venous infarct • CECT – filling defects • MRI, MRV
  • 60. Acute non-traumatic intracranial hemorrhage… Dural Sinus Thrombosis 10 yr boy Dehydrated Seizures
  • 61. Acute non-traumatic intracranial hemorrhage… Dural Sinus Thrombosis 10 yr boy Dehydrated Seizures
  • 62. Acute non-traumatic intracranial hemorrhage… Dural Sinus Thrombosis 10 yr boy Dehydrated Seizures
  • 63. Acute non-traumatic intracranial hemorrhage… Dural Sinus Thrombosis 10 yr boy Dehydrated Seizures
  • 64. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Neoplasms • Metastases – melanoma, renal, lung, breast Ca, chorio carcinoma • Pituitary adenoma • Primary tumors – GBM, choroid plexus ca • NCCT – hemg, edema +++ • CECT – some enhancement
  • 65. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Neoplasms Adenocarcinoma Esophagus
  • 66. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Neoplasms Adenocarcinoma Esophagus
  • 67. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Coagulopathy • Anti coagulation therapy  7 to10 times higher risk at therapeutic levels  2/3 are IPH; 1/3 are SDH • Thrombolytic therapy ( STK, UroK, TPA)  1% -2 % risk for acMI • Aspirin therapy – slightly increased risk
  • 68. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Coagulopathy Post TPA for AcMI
  • 69. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Coagulopathy Post TPA for AcMI
  • 70. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hemorrhagic infarct • Edema in arterial territory • Hemorrhage develops later – hours to weeks • Hemorrhage in the cortical areas
  • 71. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hemorrhagic infarct Lt weakness
  • 72. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hemorrhagic infarct Infarct 3 weeks prior Now on Anti-coagulation
  • 73. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Hemorrhagic infarct
  • 74. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Drug abuse • Cocaine – similar to HTN hemg  Aneurysms and AVMs may also bleed due to HTN surge • Heroin, Amphetamines, phencyclidine • Vasculitis like picture with angiography
  • 75. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage ISRN Neurology, vol. 2013, Article ID 124390, 5 pages, 2013 Acute Thalamic hemorrhage in a Cocaine user
  • 76. Acute non-traumatic intracranial hemorrhage… Multiple Parenchymal hemorrhages of different ages on MRI • Elderly  Chronic hypertension  Amyloid angiopathy • Young  Cavernous angiomas  Hematologic disorders
  • 77. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Other causes • Acute hemorrhagic leukoencephalopathy • PRES • Septic emboli • Mycotic aneurysms
  • 78. Acute non-traumatic intracranial hemorrhage… Intraparenchymal Hemorrhage Complications • Increased intracranial pressure • Rebleed • Edema, Herniation, infarcts • Intraventricular extension, hydrocephalus
  • 79. Acute non-traumatic intracranial hemorrhage… Imaging guidelines • NCCT – imaging of choice for suspected ICH • Surgical candidates without known cause – CTA • Old hypertensive patients – no need for CTA • Suspected mass/cavernous hemangioma – MRI • If CTA is not possible – MRA or catheter angiography
  • 80. Acute non-traumatic intracranial hemorrhage… Radiologist’s Responsibility • Diagnose • Guide further imaging • Communicate !
  • 81. Acute non-traumatic intracranial hemorrhage… Acute Non-traumatic Intracranial Hemorrhage imaging approach Dr Manohar Aribandi MD, DABR Senior Consultant Radiologist Teleradiology Solutions Hyderabad Thank You
  • 82. Acute non-traumatic intracranial hemorrhage… Acute Non-traumatic Intracranial Hemorrhage imaging approach Dr Manohar Aribandi MD, DABR Senior Consultant Radiologist Teleradiology Solutions Hyderabad Thank You