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Imaging in stroke and vascular disease—part 2: intracranial haemorrhage and related pathologies
  1. Shelley Renowden
  1. Correspondence to Dr Shelley Renowden, Department of Neuroradiology, Frenchay Hospital, Bristol, UK; shelley.renowden{at}nbt.nhs.uk

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Spontaneous intracranial haemorrhage (ICH) accounts for 10–15% of strokes. The pattern of haemorrhage, together with the patient's age and comorbidities influence the investigation and management.

Spontaneous ICH

Haemorrhage may be parenchymal, subdural, intraventricular or subarachnoid (SAH). The patient experiences sudden onset headache, with or without focal deficit, altered level of consciousness, seizures, nausea and vomiting. Extradural haemorrhage is usually traumatic (as is subdural), but spontaneous acute subdural haematoma may be caused by aneurysm rupture (in particular of middle cerebral and posterior communicating artery aneurysms) (figure 1), haemorrhage secondary to dural fistulas (figure 2), spontaneous intracranial hypotension, haemorrhagic dural metastases and coagulopathies.

Figure 1

Axial cranial non-contrasted CT scan (A) in a patient with sudden onset left hemiparesis and reduced level of consciousness demonstrates a spontaneous acute right-sided subdural haematoma exerting mass effect with ventricular compression and associated with extensive cortical oedema. The axial reconstruction of a CT angiogram (B) confirms that the cause is a ruptured right bifurcation MCA aneurysm.

Figure 2

Axial non-contrasted CT scans (A–C) demonstrate a haematoma in the right occipital lobe associated with a small right-sided acute subdural haemorrhage. There is compression of the right lateral ventricle and uncal herniation on the right. The sulci are generally effaced. CT angiography performed at the same time (D, axial; E and F—coronal reconstructions) confirm that the cause of the haemorrhage was a vascular malformation, probably a dural arteriovenous fistula with a prominent occipital artery supply. Lateral (G and H) and frontal (I) projections from a right external carotid angiogram confirm the presence of a right-sided arteriovenous dural fistula, supplied by branches of the right occipital and meningeal arteries, draining directly into a dilated cortical vein (almost certainly responsible for the haemorrhage), and then into the right transverse sinus. There is also a supply from dural branches of the right vertebral artery and posterior cerebral …

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