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Acute Haemorrhage

Summary

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  • Acute intracranial haemorrhage: extravasated blood within the brain parenchyma or extra-axial spaces
  • Non-contrast CT is first-line; hyperattenuation reflects clot retraction and haemoglobin concentration
  • MRI signal evolves predictably with the oxidation state of haemoglobin

Pathophysiology

  • Causes include hypertension, trauma, aneurysm rupture, vascular malformation, cerebral amyloid angiopathy, coagulopathy and haemorrhagic transformation of infarction
  • Acute clot is dense on CT owing to retraction and high protein/haemoglobin content; severe anaemia or coagulopathy can render fresh blood iso- to hypodense

Imaging

  • CT:
    • Acute haematoma is hyperdense (~50–70 HU)
    • A swirl sign of hypodense, unretracted blood suggests active bleeding
    • The CTA spot sign predicts haematoma expansion1
  • MRI (signal governed by haemoglobin state):
    • Hyperacute (oxyhaemoglobin): T1 iso/hypointense, T2 hyperintense
    • Acute (deoxyhaemoglobin): T1 isointense, T2 hypointense
    • Blooming on SWI/GRE at all stages
  • Distribution suggests aetiology: deep (hypertensive), lobar (amyloid), or along tracts/contrecoup (trauma)

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  • A hyperdense haematoma, with a thin rim of surrounding oedema, in the right frontal lobe has discharged into the right lateral ventricle.

Treatment

  • Blood pressure control and reversal of any anticoagulation
  • Surgical evacuation or external ventricular drainage in selected cases

Differential diagnosis

Differential Diagnosis (and causes of haemorrhage) Differentiating Feature
Haemorrhagic transformation of an infarct Arterial territory diffusion restriction on MRI beyond the haematoma
Subdural Haemorrhage Crescentic extra-axial collection crossing sutures
Epidural Haemorrhage Biconvex extra-axial collection not crossing sutures
Tumour Mass effect, surrounding oedema, enhancement with contrast
Contusion History of trauma, coup-contrecoup pattern
Venous Sinus Thrombosis Empty delta sign, cord sign on CT/MRI
Arteriovenous Malformation Serpiginous flow voids, calcifications
Amyloid Angiopathy Lobar microhaemorrhages, superficial/lobar distribution
Arteriolosclerosis Basal ganglia small vessel disease and microhaemorrhages
Coagulopathy Abnormal coagulation profile, multiple bleeds

  1. Wada et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. 2007. Stroke - Open in new tab. ↩