Intracranial Hemorrhage



Intracranial Hemorrhage


Bernadette L. Koch, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Cerebral Contusion


  • Germinal Matrix Hemorrhage


  • Diffuse Axonal Injury (DAI)


  • Cavernous Malformation


Less Common



  • Arteriovenous Malformation


  • Venous Thrombosis


  • Acute Hypertensive Encephalopathy, PRES


Rare but Important



  • Coagulopathies and Blood Dyscrasias


  • Herpes Encephalitis


  • Hemorrhagic Neoplasms


  • Cerebral Infarction, Subacute


ESSENTIAL INFORMATION


Helpful Clues for Common Diagnoses



  • Cerebral Contusion



    • Key facts



      • Post-traumatic


      • Accidental or nonaccidental


    • Imaging findings



      • Parenchymal hemorrhage: GM and contiguous subcortical WM


      • Typically adjacent to irregular bony protuberance or dural fold


      • Anterior inferior frontal and temporal lobes most common


      • ± surrounding edema


      • ± ST swelling, SDH, SAH, EDH, fracture


      • ± mass effect and herniation


      • Contrecoup injury opposite impact site, frequently more severe than coup injury


      • Coronal reformats very helpful


  • Germinal Matrix Hemorrhage



    • Key facts



      • Usually < 32 weeks; GA < 1,500 grams


      • Rare > 34 weeks gestational age


      • Rupture of germinal matrix capillaries due to alterations in CBF, ↑ in CVP, coagulopathy, capillary fragility, deficient vascular support, ↑ fibrinolysis


    • Imaging findings



      • Hemorrhage in subependymal region, usually caudothalamic notch (grade 1)


      • ± intraventricular hemorrhage (grade 2)


      • ± ventriculomegaly (grade 3)


      • ± cerebral hemorrhage (grade 4)


      • ± cerebellar parenchymal hemorrhage


      • US: Initial imaging modality of choice


  • Diffuse Axonal Injury (DAI)



    • Key facts



      • Secondary to trauma-induced axonal stretching


      • Usually high-velocity MVA


      • Hemorrhagic and nonhemorrhagic


    • Imaging findings



      • CT: Frequently normal


      • MR: Punctate hemorrhages at GW junction > corpus callosum, deep GM, and brainstem


      • GRE/SWI for optimal imaging


      • ± diffusion restriction


  • Cavernous Malformation



    • Key facts



      • a.k.a. cavernomas


      • Benign collections of closely apposed vascular spaces (“caverns”)


      • May enlarge, regress, or form de novo


      • Sporadic > > familial (autosomal dominant with variable penetrance)


    • Imaging findings



      • Hemorrhages of different ages


      • “Popcorn ball” appearance with mixed hyper/hypointense blood in locules


      • Hypointense hemosiderin rim on T2WI


      • ± surrounding edema if acute


      • GRE/SWI for optimal imaging


      • Minimal or no CE of lesion


      • ± adjacent enhancing DVA


Helpful Clues for Less Common Diagnoses



  • Arteriovenous Malformation



    • Key facts



      • Vascular malformation with AV shunting; no intervening capillary bed


      • Supratentorial > > > infratentorial


      • Usually solitary; multiple in HHT


      • Spetzler-Martin scale estimates surgical risk: Size (small, medium, large), location (noneloquent or eloquent area), and venous drainage (superficial or deep)


    • Imaging findings



      • Enlarged arteries and draining veins


      • “Honeycomb” of flow voids


      • ± calcification


      • ± hemorrhage


      • ± surrounding high signal gliosis


  • Venous Thrombosis



    • Cortical vein &/or dural sinus thrombosis



    • Patchy cortical/subcortical hemorrhages


    • Temporal lobe hemorrhage: Think vein of Labbe thrombus


  • Acute Hypertensive Encephalopathy, PRES



    • Key facts



      • Posterior reversible encephalopathy syndrome (PRES)


      • Abnormal cerebrovascular autoregulation


      • Present with headache, seizure, and altered mental status


      • Associated with hypertension, uremic encephalopathies, drug toxicity, tumor lysis syndrome, and sepsis with shock


    • Imaging findings



      • Multifocal edema in posterior parietal, occipital lobes > basal ganglia > brainstem


      • Frequently bilateral but asymmetric


      • Restricted diffusion uncommon


      • Hemorrhage in minority of lesions, may only be petechial hemorrhage on MR


Helpful Clues for Rare Diagnoses

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Intracranial Hemorrhage

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