Intracranial Hemorrhage - Inova Health System

Disclosures 

Intracranial Hemorrhage 

James G. Smirniotopoulos, M.D. 

Uniformed Services University 

Bethesda, MD 

No financial disclosures nor conflict of 

interest to report 

I’m from the Government … 

… and I here to help! 

Smirniotopoulos - USU - 2008 

Causes of Hemorrhage 

Traumatic 

Aneurysms 

Neoplastic 

Infectious 

Vasculopathy 

Vascular Malformations 

Location of Hemorrhage 

Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid 



What is Hemorrhage? 

Appearance of Hemorrhage 

Extravasation of RBCs 

– Can be microscopic … microbleeds? 

Punctate or Petechial 

– Cortical Contusion, Shearing Injury 

– Reperfusion Injury/Hemorrhagic Infarction 

Coalescent 

– Venous Infarction 

Confluent Hematoma 

Space or Membrane Limited 

– EDH, SDH, SAH, Intraventricular 



1

Whole Blood = Cells + Plasma 

Whole Blood = Cells + Plasma 

35-45 

Hu 

= 

0-10 

Hu 

= + 

Serum 

~ 55-65% 

35-45 

Hu 

= 

0-10 

Hu 

= + 

Serum 

~ 55-65% 

60-90 

Hu 

RBC’s 

~ 35-45% 

60-90 

Hu 

RBC’s 

~ 35-45% 



MR Imaging of Hemorrhage 

Blood Product: 

Oxyhemoglobin 

De-oxy Hgb 

T1W 

Iso 

Iso (1-3hr) 

T2W 

Iso 

Low (2hr) 



T1W 

T2W 

Oxyhemoglobin I I 

De-oxy Hgb I (1-3hr) 

D (2hr) 

Met-Hgb (in cells) 

Met-Hgb (in soln.) Hi 

Hi (3-14hr) 

Dead RBCs and Thrombolysis 

Low 

Hi (hrs-wks) 

Met-Hgb (in cells) B (3-14hr) 

Met-Hgb (in soln.) B 

II * ID * BD * BB * DD 

D 

B (hrs-wks) 

Hemichromes 

Hemosiderin 

Low 

Low 


Low 

Lower 

Hemichromes D D 

Hemosiderin Smirniotopoulos D - USU - 2008 

D 


Non-Penetrating Bullet 

Traumatic 

– Epidural 

– Subdural 

– Subarachnoid 

– Parenchyma 

Aneurysms 

Neoplastic 

Infectious 

Vasculopathy 




2





IED: Penetrating Injury 

Epidural Hematoma 

Usually acute clinical presentation 

Young patients, usually < 40 

– Dura firmly fixed in older pts. 

Usually unilateral 

Usually associated with Skull Fx 

Intracranial air, blood and metal fragments along wound track. 



Epidural Space 

•Scalp & Skull 

•Dura & Arachnoid 

•Pia and Brain 

•Ventricle and CSF 


EPIDURAL HEMATOMA 

Trauma -> > fracture & concussion 

Tearing/stripping of both layers 

from inner table 

Laceration of outer periosteal 

layer 

Laceration of meningeal vessels 

Inner (meningeal dura) intact 

Blood between naked bone and 

dura 

NORMAL arterial pressure 

continues to dissect 

periosteum from bone 


3


2 y.o. with dilated pupil 


Midline Herniation: Subfalcial and Downward Transtentorial 



Progressive EDH 


10 AM 


8 PM 

Subdural Hematoma 


Acute to Subacute to Chronic Presentation 

May present at All ages 

– isolated SDH in infants and the elderly 

May be bilateral 

No particular association with fracture 


•Scalp & Skull 

•Dura 

•Arachnoid 

•Pia and Brain 

•Ventricle Smirniotopoulos - USU and - 2008 

CSF 

4

Bridging Veins 



Complex Subdural Hematoma: 

Adult 

SDH: Subfalcial Herniation 

1cm pineal shift, 3cm Right-to-Left shift and Subfalcial 

Herniation 



Subdural Hematoma Stages 

Hyperdense 

 

Isodense to Brain 

Chronic Interhemispheric Subdural 

Hypodense 

Normal Brain Density 

 

Acute Subacute Chronic 

< 3 days 3d – 2 wks > 2 wks 



5

Interhemispheric Subdural 


Falx is too thick! 



Subarachnoid Hemorrhage 

Subdural = Epi - Arachnoid 

Sup Sag Sinus 

Zig-Zag into Sulci 



Arachnoid Membrane 

Massive Contusions 


Courtesy of Alice B. Smith, UCSF 


6

Contre-Coup Coup Contusion 





Contusion 



Contusion 

Contusion 



7

Contusion 

Rough Anterior Skull Base 

Cranial nerves 2-12 intact … but the patient smells badly, not bad, but 

badly … Anosmia 



Cerebral Cortical Contusion 

Shearing Injury (DWI, DAI) 

•Crowns of Gyri 

•Linear or flame shape 

•NOT in depths of Sulci 


High velocity MVA 

Shaking injury in infants 

High frequency/steep impulse impact 

– Blast Injuries 

– High velocity bullets and fragments 

Small (< 15mm) and Deep (subcortical) 

May cause significant Sx – Coma 

May produce subtle (executive functioning) 


Coma: Lesions and Locations 

Shearing Lesions are 

small (

26 y.o. . man in Coma 

Deep Lesions … including 

thalamus … “shearing injury” 

…causing coma 


thalamus … “shearing injury” 

…causing coma 

Corpus Callosum 

CT Scan 


MR Scan w/”blood sensitive” technique 

T2W 


SWI 

Corpus Callosum 

Corpus Callosum -> > Ventricle 

Dense, compact, white 

matter, bundles of 

axons 



Corpus Callosum and BG 

Unconscious Patient - CT 

Thanks to Pam Schaefer 



9

Diffuse Axonal Injury - FLAIR 


thalamus … corpus callosum 

“shearing injury” 

Diffuse Axonal Injury - SWI 





Dorsolateral Brainstem 

30 y.o. man after motor cycle crash with facial 

swelling and facial fractures. Acute alteration in 

level of awareness. 

No sulci, no cisterns, low-attenuation both temporal lobes, brainstem (midbrain) 

hyperattenuating lesion. 



Diffuse cerebral swelling 

Anoxic Damage 

Loss of Autoregulation 

“Commotio 

Cerebri” 

Secondary herniation 

– Duret Hemorrhage 

Duret Hemorrhages 

Downward displaced 

brainstem 

Kinks and compresses 

perforators 

Hemorrhagic Infarction 



10


Traumatic 

Aneurysms 

– Saccular, Fusiform, Mycotic 

– Subarachnoid hemorrhage, Siderosis 

Neoplastic 

Infectious 

Vasculopathy 


1980 2002 



Worst HA: Non-Contrast CT 




Subarachnoid Clots 


LP more sensitive than CT 

Trauma is most common cause for RBC’S S in CSF 

– Not seen as easily or as often on CT 

SAH on CT 

– Blood clot 

– Usually Aneurysm / AVM 

– Uncommon cause: neoplasm 

– Uncommon cause: spinal disease 

Morbidity 

– Vasospasm 

– Mass Effect (parenchymal hematoma) 

– Hydrocephalus 



11

Subarachnoid Space: Vasospasm 

The RBC’s release 

… ‘Evil Humors’ 

Aneurysm and Rupture 

SPASM 

- Infarction 

HEMATOMA 

- Herniation, etc. 

Re-BLEEDING 

HYDROCEPHALUS 




ANGIOGRAPHY 

– MRA & CTA: 

–Location of Aneurysm 

–Multiple (25% are) 

–Visualize "Neck“ 

–Spasm ? 

–If (-)( 

) REPEAT in 2-32 

3 wks. 


LOCATION of ANEURYSM 

–80-85% 85% Anterior Circulation 

–15-20% Posterior/Vertebral 



ACOMM Anuerysm 

Aneurysm 

Round (‘berry( 

berry’) ) shape 

Vessel bifurcation 

– natural weakness 

– exploited by high BP 

Common sites: 

– ACA < > ACOMM 

– MCA branches 

– Basilar Tip 



12

AP 

Angiography - Angiogram 

ICA Aneurysm 

Oblique 



Bilateral Carotid Aneurysms 

Pulsation Artifact 

Phase-encoding direction 



ICA Aneurysm 

Superficial Siderosis 



13


Traumatic 

Aneurysms 

Neoplastic 

– Metastatic 

– Primary 

Infectious 

Vasculopathy 



Traumatic 

Aneurysms 

Neoplastic 

– Metastatic 

Lung, Breast, Renal, Melanoma, Choriocarcinoma 

Infectious 

Vasculopathy 




Hemorrhagic Metastases 

Melanoma 

Metastasis 


Hemorrhagic 

Melanoma 

Metastasis 

Mets: Distributed by Blood 

Greatest Blood Flow 

– supratentorial 

– MCA territory 

Greatest Filtration 

– Gray-White Junction 

– Abrupt Change in Size & Number of 

Vessels 

Hematogenous Particles 

park at vessel branching 

points … 


Multifocal Nodular Lesions 

All Near Gray matter: cortex and basal ganglia 

Smirniotopoulos - USU - 2008 Smirniotopoulos - USU - 2008 

14


Traumatic 

Aneurysms 

Neoplastic 

– Primary 

GBM, Oligodendroglioma, Pituitary, CNC, PCNSL 

Infectious 

Vasculopathy 


6/15 

7/22 


Courtesy Smirniotopoulos of R.D. Zimmerman, - USU - 2008 

NY 


Oligodendroglioma 

Oligodendroglioma - Bleed 

Spontaneous Hemorrhage from fine vessels 



15

Pituitary MACRO-Adenoma 

Adenoma 



Pituitary Adenoma 

Adult Patient 

Microadenoma 

– < 10 mm 

– entirely within gland 

– Endocrine Sx. 

Prolactinoma 

Acromegaly 

Gigantism 

Cushing Disease 

Macroadenoma 

– > 10 mm 

– balloon sella 

– Visual Sx 

if >6 mm above sella 


bitemporal hemianopsia 

Pituitary Apoplexy 

Met Hemoglobin in 

Pituitary 

Macroadenoma 



Pituitary 

Macroadenoma 



16

David and Goliath 

Did Goliath have Gigantism and/or 

Acromegaly? 

He was a “Giant” 

He was an Angry Giant from HA and ICP 

Did he have a Macroadenoma? 

– David was able to sneak up to him 

bitemporal hemianopsia 

“Tunnel Vision” 

– One stone to the head killed him 

Pituitary Apoplexy 

Hemorrhage into Smirniotopoulos a macroadenoma 

- USU - 2008 

Neoplasms w/Hemorrhage 

Glioblastoma 

Oligodendroglioma 

Pituitary Adenoma 

Central Neurocytoma 

Metastases 

– Lung, Breast, Renal, Melanoma, Thyroid, 

Choriocarcinoma 



HSV Encephalitis 

Traumatic 

Aneurysms 

Neoplastic 

Infectious 

– Necrotizing Encephalitis (Herpes Simplex) 

– Angioinvasive Organism (aspergillus( 

aspergillus, mucor) 

– Mycotic Aneurysm 

Vasculopathy 




Hemorrhagic Necrosis and Atrophy 

Serpentine - Cortical Gyral 

Petechial 

Hemorrhages 

Petechial 



Encephalitis 

Meningitis 


Meningo-Encephalitis 

17

HSV Encephalitis - FLAIR 

HSV Encephalitis – T1WGd+ 



HSV Encephalitis – T2W 

HSV Encephalitis – T1WGd+ 

Hemosiderin 



HSV Encephalitis – T1W 


Cortical Petechial 


Angioinvasive Infections 

Usually immune suppressed 

– AIDS 

– Chronic Diseases (Diabetes) 

Organism causes thrombosis, or breaks 

down vessel walls, causing hemorrhage 

Typical fungal organisms 

– Aspergillus: fumigatus (highly aerobic mold) 

– Zygomycetes: : e.g. Mucormycosis 



18

Mucormycosis BG Infarction 

with Secondary Hemorrhage 


Traumatic 

Aneurysms 

Neoplastic 

Infectious 

Vasculopathy 

– Hypertension, Amyloid, , Atherosclerosis, 

Dissection, Autoimmune, Infarction 




Hemorrhagic Embolic Infarction 

vs. 

Hemorrhagic Conversion 

vs. 

Venous Infarction 

CEREBROVASCULAR DISEASE: 

“Hemorrhagic Infarction” 

ARTERIAL ETIOLOGY 

– Embolic Occlusion (MCA) 

– Herniation (PCA, AChoA) 

VENOUS ETIOLOGY 

– Sinus Thrombosis (SSST) 

– Deep infarcts in strips, parallel falx 

CONVERSION in ISCHEMIC INFARCT 

– Large Infarcts (whole MCA) 

-Anticoagulation (incl. ASA and thrombolysis) 




19

Reperfusion Injury 


NCT 


ECT 





Herniation and PCA Infarction 

PCA Infarct Tentorial Herniation 

Superior Cerebellar a. 

Oculomotor nerve (CN3) 

Trochlear nerve (CN4) 

Posterior Cerebral aa. 

Temporal Lobe Herniation 

– Compresses CN3/4 

– Compresses PCA 

Slow flow allows bleeding 


Courtesy Mauricio Castillo, M.D. UNC 


20

PCA Infarct from Herniation 

Anterior Choroidal 

Artery Infarction 

Contusion vs. Hemorrhagic Infarction 

Anterior Choroidal 

Artery Infarction 

PCA Infarction 

Cortical Gray to 

Depth of Sulcus 



Plain T1W MR 


T1W 

PD 




Normal vs. Venous Outflow Obst. 

Deoxygenated blood 

Stagnates in capillary bed 

PD 

T2W 



21



Oxyhemoglobin 

De-oxy Hgb 

T1W 

Iso 

Iso (1-3hr) 

T2W 

Iso 

Low (2hr) 

Hemorrhagic transformation 

Met-Hgb (in cells) 

Hi (3-14hr) 

Low 

Met-Hgb (in soln.) Hi 

Hi (hrs-wks) 

Hemichromes 

Hemosiderin 

Low 

Low 


Low 

Lower 

Initial CT 


24 hours later 

Herniation PCA compression & Bilateral Occipital Infarcts 

Carotid Thrombosis => MCA Clot 

ACA 

MCA 

This 53 yo man 

presented to the 

Emergency 

Department reporting 

a several hour 

history of left-sided 

hemi-body weakness 

medpix20366.jpg 

X 

MCA 

PCA 





ALWAYS compare w/ADC Map 

Repeat CT scans, two hours after admission 

DWI 

ADC Map 



22

Thrombotic Cerebral Infarction 

Venous Thrombosis and Infarction 

Two days after 

IA Thrombolysis 



CT @ 20º MR @ 0º 

Superior Sagittal Sinus Thrombosis 

CT 

T2W 

Deep hemorrhage into dead white-mater may spare cortex 



Superior Sagittal Sinus 

Thrombosis 

Sup. Sag. Sinus Thrombosis 

Dehydration 

Paraneoplastic Syndromes w/hypercoag 

Spinal Anesthesia 

Post-partum 



23

CEREBROVASCULAR DISEASE: 

HYPERTENSION 

Hypertensive Hematoma (Hemorrhage) 

Lacunar Infarction 

CEREBROVASCULAR DISEASE 

Arteriolar Sclerosis 

•Spontaneous Arteriolar Occlusion 

-lacunar infarcts 

•Spontaneous Rupture 

-”hypertensive hemorrhage” 

•Ectatic Elongation 

-Etat Crible 



ARTERIOLOSCLEROSIS 

Hyaline arteriolosclerosis 

Hyperplastic arteriolosclerosis 

"Lipohyalinosis" 



HYPERTENSIVE CVD 

Arteriolar occlusion - ischemia 

(Lacunae, Binswanger) 

Arteriolar rupture - hemorrhage 

(Hematoma-BG, Thal., etc.) 

Etat Crible (Dilated V-R) V 

(status cribrosus/cribalis) 


CEREBROVASCULAR DISEASE 

Arteriolar Sclerosis 

LACUNAE (Lacunar Infarcts) 

-Multiple 

-Small cavities (1-15 15 mm.) 

-Deep Gray and White: 

Putamen, , Thalamus, Internal 

Capsule, Pons 

Pure Motor Hemiplegia 

Arteriolosclerosis Smirniotopoulos - USU (HT) 

- 2008 

24

ARTERIOLOSCLEROSIS 

Old Lacunar Infarcts in GP 



HT HEMORRHAGE 

Putamen 

55% 

Cerebrum 

15% 

Thalamus 

10% 

Pons 

10% 

Cerebellum 

10% 


HT BLEED 

Hypertensive Hemorrhage 

Ateriolar Sclerosis 

– Hyaline arteriolosclerosis 

– Hyperplastic arteriolosclerosis 

– "Lipohyalinosis" 

Penetrating and non-anastomotic 

end-arteries and arterioles 

Deep Gray (Nuclear) Areas 


BP on presentation 185/105 

Courtesy Smirniotopoulos Doug Phillips, - USU - 2008 

UVA 

25

INTRA-CEREBRAL 

HEMORRHAGE 

Dense and Homogeneous 

Round/oval shape 

Basal ganglia/deep white 

Proportional mass effect 

Extension into ventricle 





Hypertensive Hematoma 

Usually single event 

HA, Pure motor hemiplegia, , etc. 

Expanding clot will displace white matter 

Local tissue pressure tamponade stops bleeding 

Treatment is often supportive 

– Herniation and deterioration prompt surgery 

Clot liquefies and is largely absorbed 

Hemosiderin ring 



Hypertensive Hematoma 

3 mo. p/Hypertensive Hemorrhage 

Circumscribed Mass 

Pushing Margin 



26



Hemosiderin 




81 y.o. . woman BP 200 mm Hg 

Hemosiderin 




27

6 days p/Hypertensive Bleed 

Met Hemoglobin 


Hemosiderin 





Met Hemoglobin 

BP on presentation 210/110 



UVA 


Hemorrhage into a mass 

Acute hemiplegia and confusion in a 68 year old man 

* 

Hypertensive “hit list” 

External Capsule 

Thalamus 

Dentate Nucleus 

Pons 

Lobar 


UVA 

NOTE: Vasogenic Edema 


UVA 

28

GBM 

Hypertensive Bleed vs. CCM 

Pt with only HA 

Minimal mass effect 

Pt acutely agitated 

Mass Effect 


UVA 


CCM Has Complex Blood Products 

Amyloid Angiopathy 

Minimal mass effect, at presentation, blood products already complex 

with both methemoglobin (bright) and hemosiderin (dark) 



Arteriolosclerosis vs. Amyloid 

Mar 11 Mar 30 

Long standing HT 

Location: 

– Basal Ganglia, 

Thalamus, Brainstem 

Single Event 

+/- Hypertension 

Location: 

– Usually Lobar 

– Often Multifical 

Multiple Events 

– Can be bilateral 

Mar 13 



29



Extensive Amyloid, Acute Bleed 

MRI - T2* 

Smirniotopoulos - USU - 2008 Courtesy Smirniotopoulos Howard Rowley, - USU - 2008 

M.D. 

CT 

30

Cerebral amyloid angiopathy 

Extracellular deposition of amyloid in the walls of 

brain and meningeal blood vessels 

17 biochemically distinct forms of amyloid 

B-APP, 

Cystatin C, British protein involved 

Amyloid fibrils show B-Pleated sheet 

secondary structure 

Stains: Congo red, PAS, Thyoflavin S or T 


Involvement of small arteries and 

arterioles of cerebrum, cerebellum and 

leptomeninges 

Pathological changes 

– Fibrinoid necrosis 

– Microaneurysms 




Alzheimer disease 

Lobar hemorrhage 

– Sporadic 

– Familial 

Ischemic infarct in AD 

Ischemic infarct in non-demented 

patients 


Courtesy Vince Mathews, M.D. 


Microbleeds vs. Cavernous Malformations 




“microbleeds” are BLACK … cavernous malformations are complex Black & White 


31

Arteriolosclerosis vs. Amyloid 


Long standing HT 

Location: 

– Basal Ganglia, 

Thalamus, Brainstem 

Single Event 

+/- Hypertension 

Location: 

– Usually Lobar 

Often multiple and 

progressive 

– Can be bilateral 

Traumatic 

Aneurysms 

Neoplastic 

Infectious 

Vasculopathy 


– Covered by Dr. Smith 



Summary 

Location of Hemorrhage 

Hemorrhage has many causes 

Hemorrhage has many locations 

Hemorrhage has a variable appearance 

– Especially on MRI 

Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid 



Appearance of Hemorrhage 


Thank You! 

 

Muito Obrigado 

EUXAPIT ! 

Muchas 

Gracias 

Mahalo ! 

Dank u wel ! 

Go Raibh Maith Agat 

Merci Beaucoup 

Danke Smirniotopoulos Schön - USU - 2008 

! 

32

Intracranial Hemorrhage - Inova Health System

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