Skip to main content

Advertisement

SpringerLink
Log in

Spontaneous brain parenchymal hemorrhage: an approach to imaging for the emergency room radiologist

  • Review Article
  • Published:
Emergency Radiology Aims and scope Submit manuscript

Abstract

Spontaneous intracranial hemorrhage is a neurological emergency commonly encountered by the emergency radiologist. This article reviews the approach to spontaneous brain parenchymal hemorrhage, including common causes and the role of various neuroimaging modalities in the diagnostic workup. We emphasize the need for a primary survey directed at conveying information needed for emergent clinical management of the patient and a secondary survey directed at identifying the etiology of the hemorrhage.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17

Similar content being viewed by others

References

  1. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G (1993) Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 24(7):987–993. doi:10.1161/01.STR.24.7.987

    Article  CAS  PubMed  Google Scholar 

  2. Huttner HB (2006) Comparison of ABC/2 estimation technique to computer-assisted planimetric analysis in warfarin-related intracerebral parenchymal hemorrhage. Stroke 37(2):404–408. doi:10.1161/01.STR.0000198806.67472.5c

    Article  PubMed  Google Scholar 

  3. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27(8):1304–1305. doi:10.1161/01.STR.27.8.1304

    Article  CAS  PubMed  Google Scholar 

  4. Amar AP (2012) Controversies in the neurosurgical management of cerebellar hemorrhage and infarction. Neurosurg Focus 32(4):E1. doi:10.3171/2012.2.FOCUS11369

    Article  PubMed  Google Scholar 

  5. Qureshi AI, Mendelow AD, Hanley DF (2009) Intracerebral haemorrhage. Lancet 373(9675):1632–1644. doi:10.1016/S0140-6736(09)60371-8

    Article  PubMed Central  PubMed  Google Scholar 

  6. Balami JS, Buchan AM (2011) Complications of intracerebral haemorrhage. Lancet Neurol 11(1):101–118. doi:10.1016/S1474-4422(11)70264-2

    Article  Google Scholar 

  7. Venkatasubramanian C, Mlynash M, Finley-Caulfield A, Eyngorn I, Kalimuthu R, Snider RW, Wijman CA (2011) Natural History of Perihematomal Edema After Intracerebral Hemorrhage Measured by Serial Magnetic Resonance Imaging. Stroke 42(1):73–80

    Article  PubMed Central  PubMed  Google Scholar 

  8. Fewel ME, Thompson BG, Hoff JT (2003) Spontaneous intracerebral hemorrhage: a review. Neurosurg Focus 15(4):E1

    PubMed  Google Scholar 

  9. Murthy JM (2005) Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. [Neurocrit Care] - PubMed - NCBI

  10. Zhu XL, Chan MS, Poon WS (1997) Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke 28(7):1406–1409

    Article  CAS  PubMed  Google Scholar 

  11. Delgado Almandoz JE, Schaefer PW, Forero NP, Falla JR, Gonzalez RG, Romero JM (2009) Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage. AJNR Am J Neuroradiol 30(6):1213–1221. doi:10.3174/ajnr.A1546

    Article  CAS  PubMed  Google Scholar 

  12. Sutherland GR, Auer RN (2006) Primary intracerebral hemorrhage. J Clin Neurosci 13(5):511–517. doi:10.1016/j.jocn.2004.12.012

    Article  PubMed  Google Scholar 

  13. Ruiz-Sandoval JL, Cantu C, Barinagarrementeria F (1999) Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis. Stroke 30(3):537–541. doi:10.1161/01.STR.30.3.537

    Article  CAS  PubMed  Google Scholar 

  14. Atlas SW, Grossman RI, Gomori JM, Hackney DB, Goldberg HI, Zimmerman RA, Bilaniuk LT (1987) Hemorrhagic intracranial malignant neoplasms: spin-echo MR imaging. Radiology 164(1):71–77. doi:10.1148/radiology.164.1.3588929

    Article  CAS  PubMed  Google Scholar 

  15. Livoni JP, McGahan JP (1983) Intracranial fluid-blood levels in the anticoagulated patient. Neuroradiology 25(5):335–337

    Article  CAS  PubMed  Google Scholar 

  16. Fang MC, Go AS, Chang Y, Hylek EM, Henault LE, Jensvold NG, Singer DE (2007) Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med 120(8):700–705. doi:10.1016/j.amjmed.2006.07.034

    Article  PubMed Central  PubMed  Google Scholar 

  17. Morris BS, Nagar AM, Morani AC, Chaudhary RK, Garg PA, Chudgar PD, Raut AA (2007) Blood-fluid levels in the brain. Br J Radiol 80(954):488–498. doi:10.1259/bjr/56532933

    Article  CAS  PubMed  Google Scholar 

  18. Khosravani H, Mayer SA, Demchuk A, Jahromi BS, Gladstone DJ, Flaherty M, Broderick J, Aviv RI (2013) Emergency noninvasive angiography for acute intracerebral hemorrhage. AJNR Am J Neuroradiol 34(8):1481–1487. doi:10.3174/ajnr.A3296

    Article  CAS  PubMed  Google Scholar 

  19. Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, Begtrup K, Steiner T, Recombinant Activated Factor VIIIHTI (2006) Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 66(8):1175–1181. doi:10.1212/01.wnl.0000208408.98482.99

    Article  CAS  PubMed  Google Scholar 

  20. Ondra SL, Troupp H, George ED, Schwab K (1990) The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 73(3):387–391. doi:10.3171/jns.1990.73.3.0387

    Article  CAS  PubMed  Google Scholar 

  21. Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W (2003) Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology 227(2):522–528. doi:10.1148/radiol.2272012071

    Article  PubMed  Google Scholar 

  22. Halpin SF, Britton JA, Byrne JV, Clifton A, Hart G, Moore A (1994) Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma. J Neurol Neurosurg Psychiatry 57(10):1180–1186

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  23. Yeung R, Ahmad T, Aviv RI, de Tilly LN, Fox AJ, Symons SP (2009) Comparison of CTA to DSA in determining the etiology of spontaneous ICH. Can J Neurol Sci 36(2):176–180

    Article  PubMed  Google Scholar 

  24. Wong GKC, Siu DYW, Abrigo JM, Ahuja AT, Poon WS (2012) Computed tomographic angiography for patients with acute spontaneous intracerebral hemorrhage. J Clin Neurosci 19(4):498–500. doi:10.1016/j.jocn.2011.08.017

    Article  PubMed  Google Scholar 

  25. Li Q, Lv F, Yao G, Li Y, Xie P (2013) 64-section multidetector CT angiography for evaluation of intracranial aneurysms: comparison with 3D rotational angiography. Acta Radiol. doi:10.1177/0284185113506138

    Google Scholar 

  26. Yoon DY, Chang SK, Choi CS, Kim WK, Lee JH (2009) Multidetector row CT angiography in spontaneous lobar intracerebral hemorrhage: a prospective comparison with conventional angiography. AJNR Am J Neuroradiol 30(5):962–967. doi:10.3174/ajnr.A1471

    Article  CAS  PubMed  Google Scholar 

  27. Provenzale JM, Kranz PG (2011) Dural sinus thrombosis: sources of error in image interpretation. AJR Am J Roentgenol 196(1):23–31. doi:10.2214/AJR.10.5323

    Article  PubMed  Google Scholar 

  28. Thompson AL, Kosior JC, Gladstone DJ, Hopyan JJ, Symons SP, Romero F, Dzialowski I, Roy J, Demchuk AM, Aviv RI, Group PSICS (2009) Defining the CT angiography “spot sign” in primary intracerebral hemorrhage. Can J Neurol Sci: J Can Sci Neurol 36(4):456–461

    Article  Google Scholar 

  29. Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, Symons SP (2007) CT angiography “Spot Sign” predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 38(4):1257–1262. doi:10.1161/01.STR.0000259633.59404.f3

    Article  PubMed  Google Scholar 

  30. Goldstein JN, Fazen LE, Snider R, Schwab K, Greenberg SM, Smith EE, Lev MH, Rosand J (2007) Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 68(12):889–894. doi:10.1212/01.wnl.0000257087.22852.21

    Article  CAS  PubMed  Google Scholar 

  31. Becker KJ, Baxter AB, Bybee HM, Tirschwell DL, Abouelsaad T, Cohen WA (1999) Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 30(10):2025–2032. doi:10.1161/01.STR.30.10.2025

    Article  CAS  PubMed  Google Scholar 

  32. Kim J, Smith A, Hemphill JC, Smith WS, Lu Y, Dillon WP, Wintermark M (2008) Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. Am J Neuroradiol 29(3):520–525. doi:10.3174/ajnr.A0859

    Article  CAS  PubMed  Google Scholar 

  33. Li N, Wang Y, Wang W, Ma L, Xue J, Weissenborn K, Dengler R, Worthmann H, Wang DZ, Gao P, Liu L, Wang Y, Zhao X (2011) Contrast extravasation on computed tomography angiography predicts clinical outcome in primary intracerebral hemorrhage: a prospective study of 139 cases. Stroke 42(12):3441–3446. doi:10.1161/STROKEAHA.111.623405

    Article  PubMed  Google Scholar 

  34. Demchuk AM, Dowlatshahi D, MD DR-L, MD PCAM, MD YSB, MD ID, MD AK, MD J-MB, MD CL, MD GG, MD PVP, MD JR, MD PCSK, PhD JK, MD RB, BSc ST, MD SS, MD DJG, MD PMDH, MBChB RIA, group ftPSICs (2012) Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol 11 (4):307-314. doi:10.1016/S1474-4422(12)70038-8

  35. Brouwers HB, Falcone GJ, McNamara KA, Ayres AM, Oleinik A, Schwab K, Romero JM, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN (2012) CTA spot sign predicts hematoma expansion in patients with delayed presentation after intracerebral hemorrhage. Neurocrit Care 17(3):421–428. doi:10.1007/s12028-012-9765-2

    Article  PubMed Central  PubMed  Google Scholar 

  36. Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly ES, Greenberg SM, Huang JN, Macdonald RL, Messe SR, Mitchell PH, Selim M, Tamargo RJ, Nursing obotAHASCaCoC (2010) Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 41(9):2108–2129. doi:10.1161/STR.0b013e3181ec611b

    Article  PubMed  Google Scholar 

  37. Bradley WG Jr (1993) MR appearance of hemorrhage in the brain. Radiology 189(1):15–26. doi:10.1148/radiology.189.1.8372185

    Article  PubMed  Google Scholar 

  38. Atlas SW, Mark AS, Grossman RI, Gomori JM (1988) Intracranial hemorrhage: gradient-echo MR imaging at 1.5 T. Comparison with spin-echo imaging and clinical applications. Radiology 168(3):803–807. doi:10.1148/radiology.168.3.3406410

    Article  CAS  PubMed  Google Scholar 

  39. Chavhan GB, Babyn PS, Thomas B, Shroff MM, Haacke EM (2009) Principles, techniques, and applications of T2*-based MR imaging and its special applications. Radiographics 29(5):1433–1449. doi:10.1148/rg.295095034

    Article  PubMed Central  PubMed  Google Scholar 

  40. Wang QT, Tuhrim S (2012) Etiologies of intracerebral hematomas. Curr Atheroscler Rep 14(4):314–321. doi:10.1007/s11883-012-0253-0

    Article  PubMed  Google Scholar 

  41. Blitstein MK, Tung GA (2007) MRI of cerebral microhemorrhages. Am J Roentgenol 189(3):720–725. doi:10.2214/AJR.07.2249

    Article  Google Scholar 

  42. Soffer D (2006) Cerebral amyloid angiopathy—a disease or age-related condition. Israel Med Assoc J: IMAJ 8(11):803–806

    CAS  PubMed  Google Scholar 

  43. Greenberg SM, Vernooij MW, Cordonnier C, Viswanathan A, Al-Shahi Salman R, Warach S, Launer LJ, Van Buchem MA, Breteler MM (2009) Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol 8(2):165–174. doi:10.1016/S1474-4422(09)70013-4

    Article  PubMed Central  PubMed  Google Scholar 

  44. Vernooij MW, van der Lugt A, Ikram MA, Wielopolski PA, Niessen WJ, Hofman A, Krestin GP, Breteler MM (2008) Prevalence and risk factors of cerebral microbleeds: the Rotterdam Scan Study. Neurology 70(14):1208–1214. doi:10.1212/01.wnl.0000307750.41970.d9

    Article  CAS  PubMed  Google Scholar 

  45. Woo D, Sauerbeck LR, Kissela BM, Khoury JC, Szaflarski JP, Gebel J, Shukla R, Pancioli AM, Jauch EC, Menon AG, Deka R, Carrozzella JA, Moomaw CJ, Fontaine RN, Broderick JP (2002) Genetic and environmental risk factors for intracerebral hemorrhage: preliminary results of a population-based study. Stroke 33(5):1190–1195

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Radiology, Duke University Medical Center, Durham, NC, USA

    Peter G. Kranz, Timothy J. Amrhein & James M. Provenzale

  2. Departments of Radiology, Oncology and Bioengineering, Emory University School of Medicine, Atlanta, GA, 30322, USA

    James M. Provenzale

Authors
  1. Peter G. Kranz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Timothy J. Amrhein
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. James M. Provenzale
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter G. Kranz.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kranz, P.G., Amrhein, T.J. & Provenzale, J.M. Spontaneous brain parenchymal hemorrhage: an approach to imaging for the emergency room radiologist. Emerg Radiol 22, 53–63 (2015). https://doi.org/10.1007/s10140-014-1245-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10140-014-1245-x

Keywords

Search

Navigation