Intracranial Hemorrhage (ICH)

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Diagnosis Definition

Intracranial hemorrhage (ICH) can be intracerebral (within the brain) and extracerebral (e.g., subarachnoid, subdural, and epidural)
The most common cause of ICH between ages 45 and 70 is hypertensive hemorrhage
Cerebral amyloid angiopathy (CAA) is also an important cause of spontaneous ICH in the elderly
Tumors with a propensity to bleed include glioblastoma multiforme and vascular metastatic lesions including melanoma, thyroid carcinoma, renal cell carcinoma, and choriocarcinoma
Other common causes of ICH are coagulopathy, trauma, vascular malformations, vasculitis and hemorrhagic infarction

Imaging Findings

The MR appearance of ICH is complex and depends primarily on whether the blood is in the deoxyhemoglobin, intracellular methemoglobin, extracellular methemoglobin, or hemosiderin state
Hypertensive hemorrhage most commonly occurs in the deep gray matter, brainstem and cerebellum, often with intraventricular extension
Compared with hypertensive ICH, CAA typically spares basal ganglia, uncommonly extends intraventricularly, and is associated with different ages of lobar hemorrhage
Tumor-associated hemorrhage is heterogeneous in appearance due to mixed signals of hemorrhage, nonhemorrhagic tumor tissue, cystic/necrotic change, and greater degrees of vasogenic edema

Pearls

MRI gradient echo and susceptibility-weighted imaging is superior to CT in detecting chronic hemorrhages and microbleeds, and better at identifying underlying etiology including structural lesions
Contrast-enhanced MRI can show rim enhancement of metastatic lesions as well as subacute hematomas

References

Heit JJ, Iv M, Wintermark M. Imaging of intracranial hemorrhage. J Stroke 2017; 19(1):11-27
William WG Jr. MRI of intracranial hemorrhage. Contemporary Diagnostic Radiology 2016; 39(10):1-6

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