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.
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MRI appearance of parenchymal haematoma
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.
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 (F and G) and frontal (H) 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 artery (see I, lateral projection right vertebral angiogram).
Axial non-contrasted CT scans (A–D) show a left occipital haematoma with oedema and exerting mass effect. There is generalised sulcal effacement, ventricular compression, midline shift and left-sided uncal herniation. CT angiography (E, parasagittal …