Imaging of Spontaneous Intracerebral Hemorrhage

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Key points

  • Intracerebral hemorrhage (ICH) is a devastating condition with a combined morbidity and mortality of up to 75%.

  • The aim of ICH neuroimaging is not only to confirm the diagnosis but also to establish the cause of bleeding and potentially predict the likelihood of hematoma expansion.

  • Although noncontrast computed tomography (CT) scans comprise the first line of diagnosis, further investigation with CT angiography, magnetic resonance (MR)/MR angiography, digital subtraction angiography, or advanced

Primary Brain Injury

The initial hemorrhage into the brain parenchyma causes disruption in cerebral cellular architecture.17 The added volume of hemorrhage also causes mass effect, which increases intracranial pressure (ICP). The increased ICP compresses the nearby vessels, causing cerebral ischemia. In addition, the ruptured vessels also lose their blood flow themselves because of extravasation, further worsening the ischemic damage.17

Secondary Brain Injury

Hematoma expansion (HE) usually occurs within the first 6 hours of ICH and is

Noncontrast Computed Tomography Scan

Rapid imaging with either CT or magnetic resonance (MR) to differentiate between ischemic and hemorrhagic stroke is a class I/level A recommendation per the AHA/ASA guidelines for imaging of s-ICH.16 Noncontrast CT (NCCT) is usually the study of choice in emergency departments for initial work-up of stroke because of its faster scanning time, easy availability, and its high sensitivity to detect ICH.26 In addition, it can also measure volume, mass effect, and cerebral edema in patients with

Prehospital Neuroimaging

Stroke emergency mobile units or mobile stroke units are dedicated ambulances equipped with CT scanners that are dispatched to a patient’s location when stroke is suspected.54 A study by Walter and colleagues55 proved that initial management of stroke, including thrombolysis, is clinically feasible through these mobile units at the emergency location. The study also showed that, when ICH is diagnosed by the mobile stroke unit, immediate management of blood pressure can be initiated to improve

Summary

Fig. 11 depicts a stepwise multimodal algorithm for outcome prognostication in patients with s-ICH. This algorithm is largely based on the most recent guidelines for s-ICH by the AHA/ASA. Per the guidelines, rapid neuroimaging with CT or MR imaging (class I; level of evidence A) should be performed as part of the initial evaluation of patients with ICH. CTA and contrast-enhanced CT can be considered if additional concerns for neurologic deterioration or HE are suspected (class IIb; level of

Clinics care points

  • Intracerebral hemorrhage (ICH) is a devastating condition with a combined morbidity and mortality of up to 75%.

  • The aim of ICH neuroimaging is not only to confirm the diagnosis but also to establish the cause of bleeding and potentially predict the likelihood of hematoma expansion.

  • While non-contrast CT scans comprise the first line of diagnosis, further investigation with CTA, MR/MRA, digital subtraction angiography, or advanced imaging are required to identify potential underlying etiology.

  • The

Disclosure

The authors have nothing to disclose.

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      In the world, stroke ranks in the top three leading causes of death. Despite hemorrhagic stroke making up only 20 % of all strokes, it is more dangerous than ischemic stroke because of its higher mortality rate, leaving severe complications such as paralysis, aphasia, epilepsy, and dementia that significantly affect patients’ quality of life (Jain et al., 2021). With intracerebral hemorrhage's high mortality rate and morbidity, concerns have been raised about finding effective treatments for ICH.

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