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Acute Intracerebral Hemorrhage

Ashley Davidoff MD

The Common Vein Copyright 2010

Introduction

CT

Acute Right Thalamic Hemorrhage

The CT is from a 77year old male with acute neurological deficit The epicenter of the disease is an acute hemorrhage in the right thalamus, bright red in (b,d) with extension of the clot into the ventricle (maroon). There is non clotted blood lying dependently in the occipital horns (dense on c) presenting as a CSF-blood level (light pink on black CSF) in (d). The hemorrhage is surrounded by a rim of edema (light yellow) as seen in b and d.

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Acute Hemorrhagic Stroke of the Basal Ganglia

Hemorrhage from the Perforators

Rupture into the Choroid Plexus

The CT is from a 33year old male with an acute left basal ganglial hemorrhagic stroke. The CT shows a hyperdense accumulation of hemorrhage(d) complicated by extension or rupture of the hemorrhage into the ipsilateral choroid plexus (green arrows a,b,c) and hemorrhage into the ventricles with blood lying dependently in the occipital horns (maroon arrows in c) and midline shift with septum pellucidum (white arrow of the eyes (lenses overlaid in d) mass effect on the left frontal horn (d) and midline shift exemplified by the shift of the septum pellucidum (white arrow c).

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Acute Cerebral Hemorrhage with Mass Effect and Rupture into the Ventricles
This CT shows an acute hemorrhagic event originating in the frontoparietal region of the left cerebral hemisphere causing significant mass effect by compressing and displacing the ipsilateral lateral ventricle with significant midline shift.

The hemorrhage has ruptured into the ipsilateral lateral ventricle and blood can be seen within the choroid plexus (b) in the posterior horn (c) as well as the 4th ventricle (d).

The ipsilateral edema has caused loss of the gray white matter interface in the left parietal lobe

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MRI

Aging the Hemorrhage on MRI

Hyperacute – minutes to hours

T1 – hematoma  (deoxyHb) dark => isointense

T2 – hematoma (deoxyHb) dark=> isointense

Acute – 0-2 days

deoxyhemoglobin is in intact RBCs with surrounding edema

T1- hematoma isointense, edema dark

T2 – hematoma  dark, edema bright

Subacute – 2-14 days

deoxyhemoglobin changes to methemoglobin from outer to inner

T1 – outer core bright

T2 – outer core bright due to shortened T1, longer T2

Chronic – 14 days

hemosiderin laden macrophages at periphery

T1 – inner core bright, rim dark

T2 – inner core bright, rim has low dark

Chronic – months later

hemosiderin laden macrophages at periphery

T1- mostly iso-/dark, rim is dark

T2- markedly dark rim – “blooms” with greater T2-weighting

MRI Images

Acute Thalamic Hemorrhage MRI

The MRI is from a 77year old male with acute neurological deficit The epicenter of the disease is a hemorrhage in the right thalamus. The T1 weighted image (upper left) shows mostly hypointense signal indicating the presence of deoxyhemoglobin. On the T2 weighted image the signal of the hematoma is also mostly hypointense confirming the hyperacute nature of the hematoma, surrounded by a ring of increased signal reflecting edema. There is a layering effect of blood in the posterior horn on the left The presence of deoxyhemoglobin dates the hemorrhage between minutes to hours The FLAIR image (c) shows the hyperacute hematoma as hypointense and the surrounding edema as hyperintense. The GRE image fails to reveal hemosiderin deposit in the periphery making chronic hemorrhage unlikely. The diagnosis of hyperacute intracerebral hemorrhage (minutes to hours) is therefore made by the presence of deoxyhemoglobin hypo/isointensity on the T1 weighted images and the hypointensity on T2 weighted. The suurounding edema is best seen on the T2 and FLAIR images. The extension into the ventricles is apparent on all sequences.

Courtesy Ashley Davidoff MD Copyright 2010 All rights reserved 90484c04.8

Acute Frontal Lobe hemorrhagic Infarction

The MRI in various projections confirms the presence of an acute hemorrhagic infarct in the left paracentral frontal territory. The diffusion images (top left), show a hyperintense focus in the left frontal lobe, which is hyperintense on the axial FLAIR image (middle top), hypointense and granular on the GRE (top right), hypointense on the sagittal T1 (bottom left) and seen as hyperintense on the last two STIR coronal images. These findings are consistent with an acute hemorrhagic focus which and was thought to be embolic in origin due to other noted foci. brain frontal lobe fx hyperintense focus diffusion images fx hyperintense T2 weighted STIR fx dark GRE fx dark T1 dx hemorrhagic infarction hemorrhage acute bleed dx acute hemorrhagic emboli MRI

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Acute Infarction with Rim Hemorrhage

The basal ganglia with an abnormality in the right globus pallidus are shown in axial projection in the MRI of a 64 year old male who presents with acute neurological deficit. In the first image a high intensity region in the right globus pallidus is shown in axial projection on DWI consistent with an acute infarction. The second image is a T1 weighted image without contrast and shows a rim of high intensity suggesting rim hemorrhage.. The third T2 weighted image shows the lesion to be bright but not as bright as CSF a finding consistent with the acute infarction. The fourth image is a FLAIR image and also shows increased intensity of the lesion. The constellation of findings is consistent with an acute infarction of the right globus pallidus with a rim of acute hemorrhage.

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