Spontaneous intracerebral hematomas from vascular causes

Summary The aim of the present study was to assess the diagnostic accuracy of CT in determining the underlying causes of brain hematomas with a state-of-the art CT. For this purpose, CT and angiographic data of 149 subjects with spontaneous intracerebral hematomas (ICH) were statistically compared in a blind, retrospective study, taking angiography, supported when possible by surgical findings, as providing the correct diagnoses. 5 groups were distinguished on the basis of CT data: 103 patients with isolated deep ICH had normal angiograms; 9 patients with isolated superficial ICH and 8 with deep ICH and intraventricular hemorrhage (IVH) had arteriovenous malformations (AVMs). 4 with this combination showed no angiographic abnormalities, one had an aneurysm. 14 subjects with ICH and subarachnoid hemorrhage (SAH) had a middle cerebral or carotid artery aneurysm; and 10 with ICH, SAH and IVH had also an aneurysm, in 7 on the anterior communicating artery. Sensitivity, specificity, positive and negative predictive values were respectively: for AVMs 100, 96, 77 and 100%; and for aneurysms 96, 100, 100 and 99%. Kendall coefficient was 0.95, indicating close correlation between the two modalities. This study confirms that CT can accurately predict the likelihood, nature and location of vascular ICHs. It indicates whether angiography is necessary or not, and if so, what vascular tree ought to be explored.     

Nontraumatic parietal subcortical hemorrhage: clinical-computed tomographic correlations

The clinical and computed tomographic findings in 25 patients with parietal lobe hematomas are discussed. Six patients had anterior-lateral parietal hematomas (18 to 36 mm). These patients were normotensive. No etiology was delineated even when angiography was utilized. Six patients had medial parietal hematomas (12 to 24 mm) with extension to the thalamus. Two patients were normotensive and six were hypertensive. Three patients had posterior parietal hematomas (10 to 18 mm). These patients were hypertensive. Eight patients had parietal hematomas extending to the temporal and frontal region (30 to 60 mm). Three of these patients died. Four patients were normotensive and four were hypertensive. One of these normotensive patients had cerebral metastases. Two patients had parietal hematomas which extended to the occipital region (20 to 34 mm). These patients were normotensive. Peripheral rim enhancement was demonstrated on follow-up CT scan (performed 2 to 4 weeks after the initial study) in 14 of 21 cases. On follow-up CT of the 21 surviving patients with parietal hematomas (excluding the case due to metastases) performed more than 4 weeks after the clinical ictus, 14 appeared hypodense and 7 appeared isodense. Residual neurological deficit and recurrent seizures were more frequent if the hematoma "aged" to a hypodense appearance.     

Thrombolytic therapy in myocardial infarction. Computerized tomography of encephalic complications]

PURPOSE: To evaluate the CT findings of intracerebral hemorrhage in patients undergoing thrombolytic therapy for acute myocardial infarction and to correlate the type of intracerebral hemorrhage with clinical outcome. MATERIAL AND METHODS: We retrospectively reviewed the clinical records and CT scans of intracerebral hemorrhage on a total of 302 patients who underwent thrombolytic therapy for acute myocardial infarction at our institution from January 1996 to September 1999. In each patient we evaluated: the number, sites and size of hemorrhage, and the presence and severity of mass effect. The site of the hemorrhage was classified as intraparenchymal, intraventricular, subdural and subarachnoid. RESULTS: Six patients (2%, mean age 74, range 66-80) developed intracerebral hemorrhage. There was a total of 22 hemorrhages: 1 subdural hemorrhage, 6 subarachnoid, 11 intraparenchymal and 4 intraventricular. Excluding intraventricular hemorrhage, 14/18 hemorr-hages were located supratentorially. In five patients there was a fluid-blood level. Three patients had severe mass effect with midline shift. Symptoms presented within 24 hours from the administration of thrombolytic therapy in all patients. All the patients who died had a large hematoma with a severe mass effect and a severe midline shift at CT scan. In the remaining patients, the hematoma was of medium size and no mass effect was seen. CONCLUSIONS: The most common site of hemorrhage was supratentorial and intraparenchymal. Large volume intracerebral hemorrhage, multiple hemorrhages and mass effect with midline shift were associated with increased mortality. The most commonly observed finding was a fluid-blood level hematoma.     

Multiple cerebral aneurysms in identical twins.

We report the finding of multiple cerebral aneurysms in a pair of identical twins. One twin had subarachnoid hemorrhage and intracerebral hematoma; her sister had subarachnoid hemorrhage and intraventricular bleeding. Angiography in both cases showed multiple cerebral aneurysms. It is appropriate to recommend a cerebral angiographic examination of an asymptomatic twin after the other twin has suffered an aneurysmal subarachnoid hemorrhage.     

颅内动脉瘤破裂出血的CT诊断潜能

目的研究CT对颅内动脉瘤破裂出血的诊断潜能。方法对68例动脉瘤破裂的患者的CT表现进行分析,并与金标准DSA对照。结果首发蛛网膜下腔出血38例,脑内血肿11例,蛛网膜下腔出血并硬膜下出血1例,颅内血肿5例,脑室出血2例,脑积液4例,血管痉挛1例;动脉瘤破裂治疗中出现脑血管痉挛18例,脑积液11例。结论CT可显示动脉瘤破裂的一些特征性表现,能够根据不同脑池内积液、脑内血肿的特征性分布大致提示动脉瘤的部位。     

Nontraumatic temporal subcortical hemorrhage

Summary Thirty patients with temporal hematomas were analyzed. Four with frontal extension survived. Of 6 with ganglionic extension, three had residual deficit. Of 8 with parietal extension, 4 had delayed deterioration and died, two patients recovered, and two with peritumoral hemorrhage due to glioblastoma multiforme died. Five patients with posterior temporal hematomas recovered. In 7 patients with basal-inferior temporal hematomas, angiography showed aneurysms in 3 cases, angiomas in 2 cases and no vascular lesion in 2 cases. Of 23 cases with negative angiography and no systemic cause for temporal hematoma, 12 patients were hypertensive and 11 were normotensive. Ten hypertensive patients without evidence of chronic vascular disease had the largest hematomas, extending into the parietal or ganglionic regions. Seven of these patients died; 3 had residual deficit. Eleven normotensive and two hypertensive patients with evidence of chronic vascular change had smaller hematomas. They survived with good functional recovery.     

Detection of intracranial aneurysms: multi-detector row CT angiography compared with DSA

PURPOSE: To prospectively compare the effectiveness of multi-detector row computed tomographic (CT) angiography with that of conventional intraarterial digital subtraction angiography (DSA) used to detect intracranial aneurysms in patients with nontraumatic acute subarachnoid hemorrhage. MATERIALS AND METHODS: Thirty-five consecutive adult patients with acute subarachnoid hemorrhage were recruited into the institutional review board-approved study and gave informed consent. All patients underwent both multi-detector row CT angiography and DSA no more than 12 hours apart. CT angiography was performed with a multi-detector row scanner (four detector rows) by using collimation of 1.25 mm and pitch of 3. Images were interpreted at computer workstations in a blinded fashion. Two radiologists independently reviewed the CT images, and two other radiologists independently reviewed the DSA images. The presence and location of aneurysms were rated on a five-point scale for certainty. Sensitivity and specificity were calculated independently for image interpretation performed by the two CT image readers and the second DSA image reader by using the first DSA reader's interpretation as the reference standard. RESULTS: A total of 26 aneurysms were detected at DSA in 21 patients, and no aneurysms were detected in 14 patients. Sensitivity and specificity for CT angiography were, respectively, 90% and 93% for reader 1 and 81% and 93% for reader 2. The mean diameter of aneurysms detected on CT angiographic images was 4.4 mm, and the smallest aneurysm detected was 2.2 mm in diameter. Aneurysms that were missed at initial interpretation of CT angiographic images were identified at retrospective reading. CONCLUSION: Multi-detector row CT angiography has high sensitivity and specificity for detection of intracranial aneurysms, including small aneurysms, in patients with nontraumatic acute subarachnoid hemorrhage.     

外伤性迟发性脑内血肿的早期CT表现

目的　研究外伤性迟发性脑内血肿的早期CT表现 ,评价这些表现对迟发性脑内血肿的预期诊断意义。方法　搜集CT复查证实的外伤性迟发性脑内血肿 31例 ,对其首次CT检查及复查的CT影像特点进行分析。按时间顺序抽取脑外伤后复查无脑内血肿病人 5 0例作为对照。统计处理2组观察结果。结果　 31例迟发性脑内血肿首次CT检查主要异常表现包括 :(1)限局性脑实质密度减低 ,灰白质分界不清 18例。 (2 )限局性蛛网膜下腔出血 2 4例。 (3)局部脑轻度占位效应 16例。 (4 )硬膜下血肿 9例。统计学显示与无迟发性脑内血肿差异有显著性意义 (χ2 =4 5× 10 -10 ,2 7 98,19 5 7,10 5 4,P值均 <0 0 1)。同时盲法测试结果显示 ,作者与盲法观察结果差异无显著性意义 (χ2 =1 0 3,0 34 ,2 81,P值均 >0 0 5 )。结论　脑外伤后首次行CT检查 ,出现局部脑实质密度减低 ,灰白质分界不清 ;局部蛛网膜下腔出血及脑占位效应 ,提示此部位可能出现迟发性脑内血肿 ,应及时做CT复查     

Nontraumatic hemorrhage in abdomen and retroperitoneum--CT, sonographic and clinical findings

Sixteen patients with nontraumatic abdominal or retroperitoneal hemorrhage were examined with ultrasound (n = 16), and CT (n = 14). The lesions of the 10 patients with signs on the onset of hemorrhage were four rectus sheath hematomas, three renal subcapsular and perirenal hematomas, and subcapsular hematoma, pararenal hematoma, perirenal and parenal hematoma, on each. Fall in periphery blood hematocrit values within 24 hours after the onset was observed in only three patients. As the hematocrit value was increased, fluid area of hematoma was replaced by high density on CT and by hypoechoic area on ultrasound. The lesions of the remaining 6 patients were four renal subcapsular hematomas, one hepatic parenchymal and subcapsular hematoma, and one iliopsoas hematoma. CT is superior to ultrasound in evaluation of the nontraumatic hematomas. However, clinicians require to pay more attention to this disorder which occasionally mimick other disorders.     

Intraventricular hemorrhage in adults: clinical-computed tomographic correlations

The clinical and computed tomographic (CT) findings in 100 consecutive adult nontraumatic intraventricular hemorrhage (IVH) cases are analyzed. There were 74 parenchymal brain hemorrhages with secondary ventricular extension. The ventricles were filled with blood and asymmetrically enlarged. If the hemorrhage involved putamen, cerebellum, pons, or subcortical cerebral hemispheric white matter, IVH was associated with large parenchymal hematomas; these patients had poor clinical outcome. With thalamic or caudate hematomas, IVH frequently occurred with large hematomas but may occur with small hematomas. The small hematomas were located directly contiguous to the ventricular walls and caused extensive ventricular blood. Patients with small thalamic and caudate hemorrhage with intraventricular blood had good clinical outcome; whereas patients with large hematomas had poor outcome. Primary IVH occurred in 24 cases. In these cases, blood was seen in all ventricular chambers. Aneurysms involving the anterior cerebral-anterior communicating artery region were the most common etiology for primary IVH.     

CT angiography of cerebral vasospasm with conventional angiographic comparison.

Two patients with subarachnoid hemorrhage underwent CT angiography and conventional angiography at presentation. In each patient, both studies were repeated after the onset of intracranial vasospasm. In both cases, CT angiograms were able to demonstrate convincingly the conventional angiographic findings. CT angiography may prove useful in the evaluation of vasospasm in patients with subarachnoid hemorrhage.     

晚发性维生素K缺乏致颅内出血的CT表现及临床意义探讨

目的：探讨晚发性维生素Ｋ缺乏致颅内出血的ＣＴ诊断、疗效观察及预后判断。材料与方法：对８年间所诊断的８４例患儿临床资料及ＣＴ资料进行回顾性分析。结果：ＣＴ显示颅内出血率为９０．５％，蛛网膜下腔出血最多见，其次为硬是出血、脑内出血，脑室内出血少见；有２个以上出血部位者占６１．９％，可出现大片脑梗褰主脑缺氧缺血性病变。硬膜下血肿及蛛网膜下腔出血吸较完全，脑内血肿范围较大，特别是伴胸有成竹离梗塞得可有脑国     

Evaluation of subarachnoid hemorrhage and cerebral vasospasm by computed tomography.

The CT findings in patients with subarachnoid hemorrhage include visualization of the aneurysm (10% of the cases), subarachnoid, intraventricular, or intracerebral hemorrhage (87% of cases scanned within five days), "ischemic" lucency secondary to spasm (10%), and hydrocephalus (54%).     

Dural arteriovenous malformation associated with subdural and intracerebral hematoma: a CT scan and angiographic correlation

Computed tomography of a case of hemorrhage from a dural arteriovenous malformation depicts an occipital varix with dilated venous channels, an intracerebral hematoma, a subdural hematoma and a subfacial hernation. The angiographic and surgical findings are described.     

Subarachnoid hemorrhage associated with cyclosporine A neurotoxicity in a bone-marrow transplant recipient

We report subarachnoid hemorrhage associated with cyclosporine A (CSA) neurotoxicity after bone-marrow transplantation for chronic myelogenous leukemia. CT showed occipital subarachnoid hemorrhage. MRI confirmed this, and demonstrated cortical and subcortical edema in the posterior temporal, occipital, and posterior frontal lobes bilaterally, which was typical of CSA neurotoxicity. Recognition of CSA neurotoxicity as the cause of the subarachnoid hemorrhage obviated angiographic investigation. After cessation of cyclosporine therapy, the cortical and subcortical edema resolved on follow-up MRI with some residual blood products in the subarachnoid space. Received: 6 May 2000 Accepted: 1 August 2000     

Intracerebral hemorrhage caused by cerebral amyloid angiopathy: radiographic-pathologic correlation

Seven cases of nontraumatic intracerebral hemorrhage due to histologically confirmed cerebral amyloid angiopathy were observed over a period of 2 1/2 years. Initial computed tomographic (CT) scans demonstrated lobar hemorrhages in all but one patient, who had presented with corpus callosum hemorrhage. Superficial location, irregular borders, and surrounding edema were characteristic features. Angiography was performed in three cases. Findings included mass effect (three cases), opercular branch occlusion (one case), and pericallosal irregularity (one case), all in the areas of the hemorrhage. Clinically, none of the patients had a history of prior cerebrovascular disease. Mild hypertension had been present in three patients and dementia in two. These findings suggest that cerebral amyloid angiopathy is not a rare cause of atraumatic lobar hemorrhage, particularly in a normotensive, elderly population.     

CT and MR findings of anthrax meningoencephalitis: report of two cases and review of the literature

Anthrax meningoencephalitis is a rare complication of infection with Bacillus anthracis and generally produces a hemorrhagic meningoencephalitis. We present the CT and MR imaging findings in two patients demonstrating subarachnoid, intracerebral, and intraventricular hemorrhage with leptomeningeal enhancement.     

Flat Detector Angio-CT following Intra-Arterial Therapy of Acute Ischemic Stroke: Identification of Hemorrhage and Distinction from Contrast Accumulation due to Blood-Brain Barrier Disruption

BACKGROUND AND PURPOSE:Flat panel detector CT in the angiography suite may be valuable for the detection of intracranial hematomas; however, abnormal contrast enhancement frequently mimics hemorrhage. We aimed to assess the accuracy of flat panel detector CT in detecting/excluding intracranial bleeding after endovascular stroke therapy and whether it was able to reliably differentiate hemorrhage from early blood-brain barrier disruption.MATERIALS AND METHODS:Seventy-three patients were included for retrospective evaluation following endovascular stroke therapy: 32 after stent-assisted thrombectomy, 14 after intra-arterial thrombolysis, and 27 after a combination of both. Flat panel CT images were assessed for image quality and the presence and type of intracranial hemorrhage and BBB disruption by 2 readers separately and in consensus. Follow-up by multisection head CT, serving as the reference standard, was evaluated by a single reader.RESULTS:Conventional head CT revealed intracranial hematomas in 12 patients (8 subarachnoid hemorrhages, 7 cases of intracerebral bleeding, 3 SAHs plus intracerebral bleeding). Image quality of flat panel detector CT was considered sufficient in all cases supratentorially and in 92% in the posterior fossa. Regarding detection or exclusion of intracranial hemorrhage, flat panel detector CT reached a sensitivity, specificity, positive and negative predictive values, and accuracy of 58%, 85%, 44%, 91%, and 81%, respectively. Maximum attenuation measurements were not valuable for the differentiation of hemorrhage and BBB disruption.CONCLUSIONS:Flat panel CT after endovascular stroke treatment was able to exclude the rare event of an intracranial hemorrhage with a high negative predictive value. Future studies should evaluate the predictive value of BBB disruptions in flat panel detector CT for the development of relevant hematomas.

Flat panel detectors in modern angiographic C-arm systems allow almost instant access to CT-like cranial imaging in the angiography suite.^1–4 While flat panel detector CT (FPCT) is currently not reliable in depicting ischemic brain lesions, it proved to be a sensitive tool for the detection of intracranial hematomas in both experimental and clinical settings.^5,6 However, there have been numerous reports of abnormal contrast enhancement following neurovascular interventions that frequently mimic subarachnoid, intraventricular, or intracerebral hemorrhage.^7–9 It is important to recognize such patterns of temporary blood-brain barrier disruption in postprocedural imaging because misinterpretation may unnecessarily delay anticoagulant/antiaggregant treatment.In the present study, we aimed to assess the diagnostic accuracy of FPCT for the detection of intracranial bleeding immediately after endovascular stroke therapy and whether it was able to reliably differentiate hemorrhage from early blood-brain barrier disruption.     

Diagnosis of subarachnoid hemorrhage

OBJECTIVES AND METHODS: A total of 115 patients with subarachnoid hemorrhage were retrospectively analyzed with the aim to evaluate the timing and reliability of the applied diagnostic procedures. In the group of 63 patients the reliability of CT as the diagnostic procedure was investigated, and CT scan was correlated with the clinical status of the respective patient. In the group of 79 patients with operatively treated cerebral aneurysm the angiographic and intraoperative findings were mutually compared and discrepancies were analyzed. RESULTS: During the first 48 hours after the hemorrhage, only 35.2% of all the angiographies were performed, so the final diagnosis was late in 64.8% of patients. Hemorrhage was diagnosed by CT in 87.3% of the cases and pronounced correlation existed between CT and the clinical status of the patient. Discrepancies between angiographic and operative findings existed in 16.4% of patients. CONCLUSION: CT should be the initial procedure for the diagnosis of subarachnoid hemorrhage. In nonmoribund patients the early angiography should also be performed. The main reason for delaying in diagnosis is the overdue transfer of the patients to the referral hospitals.     

Cerebral schistosomiasis: MR and CT appearance.

After returning from Africa, a 54-year-old man began to have episodes of headache and nausea, then a cerebral convulsion. Clinical and laboratory findings and response to chemotherapy indicated the diagnosis of cerebral schistosomiasis. Three lesions were seen on CT and MR studies: two appeared to be subacute intracerebral hematomas, one in the right parietal lobe and one in the frontal lobe; the third lesion, in the cortex of the left occipital lobe, appeared to be a cyst. These lesions could represent small granulomatous tissue reactions with secondary hemorrhages.