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Intracranial Hemorrhage
Eric Swart MS3 Gillian Lieberman, MD January 2007 Intracranial Hemorrhage and Sequelae Eric Swart, Harvard Medical School Year III Gillian Lieberman, MD Eric Swart MS3 Gillian Lieberman, MD Agenda • Patient Presentation • Brief review of neuroanatomy • Causes of hemorrhage and radiologic appearance • Imaging principles of blood • Physiology and consequences of hemorrhage 2 Eric Swart MS3 Gillian Lieberman, MD Patient 1 • 83 y/o M with IDDM, CAD, and CRI presents s/p fall in home with RU extremity redness. • Further history reveals multiple minor falls over past month associated with dizziness and minor head trauma. • Current medications include ASA • Any imaging? 3 Eric Swart MS3 Gillian Lieberman, MD Our Patient: Admission CT Axial CT of head, initially read as “normal” Lesion on falx? Courtesy of Dr. Handwerker 4 Eric Swart MS3 Gillian Lieberman, MD Our Patient: Head CT Hospital Day 3 Pt found unresponsive in a.m. Courtesy of Dr. Handwerker 5 Eric Swart MS3 Gillian Lieberman, MD Our Patient: Subdural Hematoma Midline shift Layering Hemorrhage Possible Subarachnoid Compression of ventricles 6 Courtesy of Dr. Handwerker Eric Swart MS3 Gillian Lieberman, MD Anatomy Review Epidural Subdural Intraparenchymal 7 http://www.surgery.ucsf.edu Eric Swart MS3 Gillian Lieberman, MD Companion Pt 1: Epidural Hematoma on CT • Usually due to trauma (deceleration) • Brief lucid interval • Laceration of the meningeal arteries (although can be venous!) • “Lentiform” • Does not cross sutures http://www.muhealth.org/~neuromed/ 8 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 2: Epidural Hematoma on CT Hematoma Courtesy of Dr. Handwerker 9 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 2: Cranial Fracture on CT Fracture Courtesy of Dr. Handwerker 10 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 4: Subdural Hematoma on CT • Usually due to trauma (shearing) • Gradual onset of sx • Tears in the small bridging veins • Crescent-shaped • Can cross sutures, but not midline http://www.sbhemresidency.com/ 11 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 5: Subdural Hematoma? Hypodense lesion, possible chronic bleed? Courtesy of Dr. Handwerker 12 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 5: Subdural Hematoma? Axial Diffusion Weighted MRI Hyperintense lesion in subdural space 13 Courtesy of Dr. Handwerker Eric Swart MS3 Gillian Lieberman, MD Companion Pt 5: Subdural Empyema Coronal T1 MRI Post-Contrast Hyperintense lesion in subdural space and in sinuses, found to be pus at surgery. 14 Courtesy of Dr. Handwerker Eric Swart MS3 Gillian Lieberman, MD Companion Pt 6: Subarachnoid Hemorrhage on CT • Causes include traumatic, aneurysm, AVM, tumor. • Same space as intraventricular hem. • “Worst headache ever” • “Star pattern” Blood in Suprasellar Sulcus http://www.emedicine.com/ Courtesy of Dr. Handwerker 15 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 7: Traumatic Subarachnoid Hemorrhage on CT Peripheral blood in sulci http://www.uth.tmc.edu/radiology/ 16 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 8: MCA Aneurysm • Common locations: – – – – Axial CTA Anterior communicating MCA Posterior communicating Basilar 17 Courtesy of Dr. Handwerker Eric Swart MS3 Gillian Lieberman, MD Companion Pt 9:Non-Aneurysmal Bleed (Perimesencephalic Hemorrhage) Blood in interpeduncular fossa Blood peripheral to midbrain 18 Courtesy of Dr. Handwerker Eric Swart MS3 Gillian Lieberman, MD Companion Pt 10:Intraparenchymal Hemorrhage on CT • Causes include traumatic, CVA, HTN, tumor, coagulopathy, AVM. • Commonly involve basal ganglia, thalamus, pons, and cerebellum • Round or irregular lesions http://www.uhrad.com 19 Eric Swart MS3 Gillian Lieberman, MD Diffuse Axonal Injury • Results from shearing trauma • Diffuse, bilateral injury at the grey-white matter junction • CT: multiple small intraparenchymal hem. • MRI may be more sensitive 20 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 11: Diffuse Axonal Injury on CT 21 Courtesy of Dr. Kang Eric Swart MS3 Gillian Lieberman, MD 30 Days in the Life of a Hemorrhage • Five distinct stages of a intracranial hemorrhage: – – – – – Hyperacute: <12 hours Acute: 12 h – 2 days Early subacute: 2 – 7 days Late subacute: 8 days – 1 month Chronic >1 month – years • Imaging principles: – Clot density changes dominate on CT – Changes in hemoglobin dominate on MR 22 Eric Swart MS3 Gillian Lieberman, MD CT Appearance of Aging Hemorrhage • Clot is initially liquid mix of RBC’s, WBC’s, platelets, and serum. – hyperacute = isointense • As the clot contracts, the core becomes denser while the surrounding areas become edematous. – acute – early subacute = hyperintense • Over time, the clot degrades, and the edema subsides. – late subacute – chronic = isointense-hypointense, may enhance with contrast due to BBB breakdown 23 Eric Swart MS3 Gillian Lieberman, MD MRI Appearance of Aging in Hemorrhage Time Iron Magnetic Status Hyperacute Intracellular oxygenated hemoglobin Diamagnetic Acute Intracellular deoxygenated hemoglobin Paramagnetic Early Subacute Intracellular methemoglobin Paramagnetic Late Subacute Extracellular methmoglobin Paramagnetic Chronic Hemosiderin and ferritin in macrophages Superparmagnetic 24 Eric Swart MS3 Gillian Lieberman, MD Summary: Appearance of Hemorrhage on CT and MRI Time CT MR T1 MR T2 Hyperacute: < 12 hours – – ↑ Acute: 12 h – 2 days ↑ – ↓ Early subacute: 2 – 7 days ↑ ↑ ↓ Late subacute: 8 days – 1 month – ↑ ↑ Chronic: >1 month – years –↓ ↓ ↑ = Hyperintense = Isointense = Hypointense 25 Eric Swart MS3 Gillian Lieberman, MD Herniation http://uptodate.com http://www.uth.tmc.edu/radiology/ 26 Eric Swart MS3 Gillian Lieberman, MD Anatomy Review Part 2 Falx Tentorium (Note the proximity of critical brainstem and cranial nerve structures) http://biocfarm.unibo.it/ 27 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 12: Subfalcine Herniation on CT • Singulate gyrus on medial aspect of frontal lobe is displaced across the midline across the free edge of the falx • May compromise ACA flow Midline shift of singulate gyrus under falx http://www.emedicine.com 28 Eric Swart MS3 Gillian Lieberman, MD Transtentorial Herniation • Medial aspect of temporal lobe (uncus) migrates across tentorium • Causes 3rd nerve compression • Can also be ascending herniation, most often from tumor in posterior fossa 29 Eric Swart MS3 Gillian Lieberman, MD Companion Patients 13 and 14: Transtentorial Herniation on CT http://rad.usuhs.mil/rad/herniation/ http://www.geocities.com/drweightloss 30 Eric Swart MS3 Gillian Lieberman, MD Central Herniation • Diffuse increase in ICP displaces each cerebral hemisphere downward through tentorium • Compresses upper brainstem 31 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 15: Tonsilar Herniation on MRI • Increased pressure develops in the posterior fossa, displacing cerebellar tonsils downward through the foramen magnum • Compresses lower brainstem and upper cervical cord Sagital T1 MRI Lesion (flow artifact indicates likely aneurysmal) Cerebellar tonsils herniating through foramen magnum http://www.kem.edu/dept/radiology/ 32 Eric Swart MS3 Gillian Lieberman, MD Companion Pt 16: Extracranial Hernation on CT http://www.emedicine.com/ 33 Eric Swart MS3 Gillian Lieberman, MD Summary • Intracranial hemorrhage is defined by its location with respect to the meninges – Trauma is usually the most common cause • Hemorrhage undergoes a predictable temporal sequence of changes that can be seen on MR and CT and used to estimate the age of the bleed. • An increase in mass can cause increased ICP and can result in extremely dangerous herniations. – Dural reflections are commonly involved 34 Eric Swart MS3 Gillian Lieberman, MD Acknowledgements Thanks to: • Gillian Lieberman, MD • Jason Handwerker, MD • James Kang, MD • Pamela Lepkowski • Larry Barbaras 35 Eric Swart MS3 Gillian Lieberman, MD • • • • • • • • • • • • • • • • • • References Huisman, TA. Intracranial hemorrhage: ultrasound, CT, and MRI findings. European Radiology 2005; 15:434-440. Parizel PM, Makkat S, Van Miert E, van Goethem JW, van den Hauwe L, De Schepper AM. Intracranial hemorrhage: principles of CT and MRI interpretation. European Radiology 2001; 11:1770-1783 Ruigrok, YM, Rinkel, GJ, Buskens, E, et al. Perimesencephalic hemorrhage and CT angiography: A decision analysis. Stroke 2000; 31:2976. Noveline, RA. Squire’s Fundamentals of Radiology 6th edition. Cambridge, 2004. Grossman RI, Yousem DM. Neuroradiology: The Requisites 2nd edition. 2003. Nolte, J. The Human Brain: An Introduction to Its Functional Anatomy 5th edition. 2002. Moore, KL, Daley, AF. Clinically Oriented Anatomy 4th edition. 1999. http://uptodate.com http://www.surgery.ucsf.edu http://www.muhealth.org/~neuromed/ http://www.sbhemresidency.com/ http://www.uth.tmc.edu/radiology/ http://emedicine.com http://www.uhrad.com http://biocfarm.unibo.it/ http://rad.usuhs.mil/rad/herniation/ http://www.geocities.com/drweightloss http://www.kem.edu/dept/radiology/ 36