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Intracranial HemorrhageIntracranial HemorrhageJames G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.
Uniformed Services UniversityUniformed Services UniversityBethesda, MDBethesda, MD
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
DisclosuresDisclosures
No financial disclosures nor conflict of No financial disclosures nor conflict of interest to reportinterest to report
I’m from the Government …
… and I here to help!
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Causes of HemorrhageCauses of Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Location of HemorrhageLocation of Hemorrhage
Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
What is Hemorrhage?What is Hemorrhage?
ExtravasationExtravasation of of RBCsRBCs–– Can be microscopic Can be microscopic …… microbleedsmicrobleeds??
PunctatePunctate or or PetechialPetechial–– Cortical Contusion, Shearing InjuryCortical Contusion, Shearing Injury–– Reperfusion Injury/Hemorrhagic InfarctionReperfusion Injury/Hemorrhagic Infarction
CoalescentCoalescent–– Venous InfarctionVenous Infarction
Confluent HematomaConfluent HematomaSpace or Membrane LimitedSpace or Membrane Limited–– EDH, SDH, SAH, IntraventricularEDH, SDH, SAH, Intraventricular
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Appearance of HemorrhageAppearance of Hemorrhage
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Whole Blood = Cells + PlasmaWhole Blood = Cells + Plasma
= +
RBC’s
~ 35-45%
Serum
~ 55-65%35-45
Hu
60-90 Hu
0-10 Hu
=
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Whole Blood = Cells + PlasmaWhole Blood = Cells + Plasma
= +
RBC’s
~ 35-45%
Serum
~ 55-65%35-45
Hu
60-90 Hu
0-10 Hu
=
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin IsoIso IsoIsoDeDe--oxy Hgboxy Hgb IsoIso (1(1--3hr)3hr) LowLow (2hr)(2hr)
MetMet--Hgb (in cells)Hgb (in cells) HiHi (3(3--14hr)14hr) LowLow
MetMet--Hgb (in soln.) Hgb (in soln.) HiHi HiHi (hrs(hrs--wks)wks)
HemichromesHemichromes LowLow LowLowHemosiderinHemosiderin LowLow LowerLower
Dead RBCs and Thrombolysis
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin II IIDeDe--oxy Hgboxy Hgb II (1(1--3hr)3hr) DD (2hr)(2hr)
MetMet--Hgb (in cells)Hgb (in cells) BB (3(3--14hr)14hr) DD
MetMet--Hgb (in soln.) Hgb (in soln.) BB BB (hrs(hrs--wks)wks)
HemichromesHemichromes DD DDHemosiderinHemosiderin DD DD
II * ID * BD * BB * DD
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumatic–– EpiduralEpidural–– SubduralSubdural–– SubarachnoidSubarachnoid–– ParenchymaParenchyma
AneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
NonNon--Penetrating BulletPenetrating Bullet
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NonNon--Penetrating BulletPenetrating Bullet
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
NonNon--Penetrating BulletPenetrating Bullet
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
IED: Penetrating InjuryIED: Penetrating Injury
Intracranial air, blood and metal fragments along wound track.
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Epidural HematomaEpidural Hematoma
Usually acute clinical presentationUsually acute clinical presentationYoung patients, usually < 40Young patients, usually < 40–– Dura firmly fixed in older pts.Dura firmly fixed in older pts.
Usually unilateralUsually unilateralUsually associated with Skull Usually associated with Skull FxFx
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Epidural SpaceEpidural Space
•Scalp & Skull
•Dura & Arachnoid
•Pia and Brain
•Ventricle and CSFSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008
EPIDURAL HEMATOMAEPIDURAL HEMATOMATrauma Trauma --> fracture & concussion> fracture & concussionTearing/stripping of both layers Tearing/stripping of both layers
from inner tablefrom inner tableLaceration of outer periosteal Laceration of outer periosteal
layerlayerLaceration of meningeal vesselsLaceration of meningeal vesselsInner (meningeal dura) intactInner (meningeal dura) intactBlood between naked bone and Blood between naked bone and
duraduraNORMAL arterial pressure NORMAL arterial pressure
continues to dissect continues to dissect periosteumperiosteum from bonefrom bone
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Epidural HematomaEpidural Hematoma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
2 y.o. with dilated pupil2 y.o. with dilated pupil
Midline Herniation: Subfalcial and Downward Transtentorial
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Epidural HematomaEpidural Hematoma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Progressive EDHProgressive EDH
8 PM10 AM
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Subdural HematomaSubdural Hematoma
Acute to Subacute to Chronic PresentationAcute to Subacute to Chronic PresentationMay present at All agesMay present at All ages–– isolated SDH in infants and the elderlyisolated SDH in infants and the elderly
May be bilateralMay be bilateralNo particular association with fractureNo particular association with fracture
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Subdural HematomaSubdural Hematoma
•Scalp & Skull
•Dura
•Arachnoid
•Pia and Brain
•Ventricle and CSF
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Bridging VeinsBridging Veins
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Complex Subdural Hematoma:Complex Subdural Hematoma:AdultAdult
1cm pineal shift, 3cm Right-to-Left shift and SubfalcialHerniation Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
SDH: SDH: SubfalcialSubfalcial HerniationHerniation
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Subdural Hematoma StagesSubdural Hematoma Stages
Acute Subacute Chronic< 3 days 3d – 2 wks > 2 wks
Normal Brain Density
⇑
⇓
Hyperdense
Isodense to Brain
Hypodense
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Chronic Interhemispheric SubduralChronic Interhemispheric Subdural
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Interhemispheric SubduralInterhemispheric Subdural
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Subdural HematomaSubdural Hematoma
Falx is too thick!
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Zig-Zag into SulciSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Subdural = Epi Subdural = Epi -- ArachnoidArachnoidSup Sag Sinus
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Arachnoid MembraneArachnoid Membrane
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy of Alice B. Smith, UCSF
Massive ContusionsMassive Contusions
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ContreContre--Coup ContusionCoup Contusion
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ContreContre--Coup ContusionCoup Contusion
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ContreContre--Coup ContusionCoup Contusion
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ContusionContusion
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ContusionContusion
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ContusionContusion
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Cranial nerves 2-12 intact … but the patient smells badly, not bad, but badly … Anosmia
ContusionContusion
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Rough Anterior Skull BaseRough Anterior Skull Base
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
••Crowns of GyriCrowns of Gyri
••Linear or flame shapeLinear or flame shape
••NOT in depths of SulciNOT in depths of Sulci
Cerebral Cortical ContusionCerebral Cortical Contusion
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Shearing Injury (DWI, DAI)Shearing Injury (DWI, DAI)
High velocity MVAHigh velocity MVAShaking injury in infantsShaking injury in infantsHigh frequency/steep impulse impactHigh frequency/steep impulse impact–– Blast InjuriesBlast Injuries–– High velocity bullets and fragmentsHigh velocity bullets and fragments
Small (< 15mm) and Deep (subcortical)Small (< 15mm) and Deep (subcortical)May cause significant May cause significant SxSx –– ComaComaMay produce subtle (executive functioning)May produce subtle (executive functioning)
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Coma: Lesions and LocationsComa: Lesions and Locations
Subcortical Subcortical –– many neededmany neededWhite Matter White Matter –– many neededmany neededThalamus Thalamus –– few neededfew neededReticular Activating SystemReticular Activating System–– Dorsal BrainstemDorsal Brainstem–– Only one neededOnly one needed
Shearing Lesions are small (<15mm) and deep (subcortical, WM, Corpus callosum, Thalamus, Brain stem
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
FindingsFindings
No Midline shiftNo Midline shiftNo explanation for GCS of 6No explanation for GCS of 6Small hemorrhage left occipital hornSmall hemorrhage left occipital horn–– Torn subependymal veins?Torn subependymal veins?–– Shearing Injury?Shearing Injury?
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26 26 y.oy.o. man in Coma. man in Coma
CT Scan MR Scan w/”blood sensitive” technique
Deep Lesions … including thalamus … “shearing injury”
… causing coma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Corpus CallosumCorpus Callosum
T2W SWI
Deep Lesions … including thalamus … “shearing injury”
… causing coma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Corpus CallosumCorpus Callosum
Dense, compact, white matter, bundles of axons
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Corpus Callosum Corpus Callosum --> Ventricle> Ventricle
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Corpus Callosum and BGCorpus Callosum and BG
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Unconscious Patient Unconscious Patient -- CTCT
Thanks to Pam Schaefer
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Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Thanks to Pam Schaefer
Diffuse Axonal Injury Diffuse Axonal Injury -- FLAIRFLAIRDeep Lesions … including
thalamus … corpus callosum “shearing injury”
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Diffuse Axonal Injury Diffuse Axonal Injury -- SWISWI
Thanks to Pam Schaefer
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Dorsolateral BrainstemDorsolateral Brainstem
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
30 y.o. man after motor cycle crash with facial 30 y.o. man after motor cycle crash with facial swelling and facial fractures. Acute alteration in swelling and facial fractures. Acute alteration in
level of awareness.level of awareness.
No sulci, no cisterns, low-attenuation both temporal lobes, brainstem (mid-brain) hyperattenuating lesion.
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Diffuse cerebral swellingDiffuse cerebral swelling
Anoxic DamageAnoxic DamageLoss of AutoregulationLoss of Autoregulation““CommotioCommotio CerebriCerebri””Secondary herniationSecondary herniation–– DuretDuret HemorrhageHemorrhage
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
DuretDuret HemorrhagesHemorrhages
Downward displaced Downward displaced brainstembrainstemKinks and compresses Kinks and compresses perforatorsperforatorsHemorrhagic InfarctionHemorrhagic Infarction
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Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysms–– SaccularSaccular, , FusiformFusiform, , MycoticMycotic–– Subarachnoid hemorrhage, Subarachnoid hemorrhage, SiderosisSiderosisNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
1980 2002
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Worst HA: NonWorst HA: Non--Contrast CTContrast CT
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Subarachnoid HemorrhageSubarachnoid Hemorrhage
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Subarachnoid ClotsSubarachnoid Clots
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Subarachnoid HemorrhageSubarachnoid Hemorrhage
LP more sensitive than CTLP more sensitive than CTTrauma is most common cause for RBCTrauma is most common cause for RBC’’S in CSFS in CSF–– Not seen as easily or as often on CTNot seen as easily or as often on CT
SAH on CTSAH on CT–– Blood clotBlood clot–– Usually Aneurysm / AVMUsually Aneurysm / AVM–– Uncommon cause: neoplasmUncommon cause: neoplasm–– Uncommon cause: spinal diseaseUncommon cause: spinal disease
MorbidityMorbidity–– VasospasmVasospasm–– Mass Effect (parenchymal hematoma)Mass Effect (parenchymal hematoma)–– HydrocephalusHydrocephalus
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Subarachnoid Space: VasospasmSubarachnoid Space: VasospasmThe RBC’s release … ‘Evil Humors’
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Aneurysm and RuptureAneurysm and Rupture
SPASM SPASM -- InfarctionInfarction
HEMATOMA HEMATOMA -- Herniation, etc.Herniation, etc.
ReRe--BLEEDINGBLEEDING
HYDROCEPHALUSHYDROCEPHALUS
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Aneurysm and RuptureAneurysm and Rupture
ANGIOGRAPHY ANGIOGRAPHY –– MRA & CTA:MRA & CTA:––Location of AneurysmLocation of Aneurysm––Multiple (25% are)Multiple (25% are)––Visualize "NeckVisualize "Neck““––Spasm ?Spasm ?––If (If (--) REPEAT in 2) REPEAT in 2--3 wks.3 wks.
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Aneurysm and RuptureAneurysm and Rupture
LOCATION of ANEURYSMLOCATION of ANEURYSM––8080--85% Anterior Circulation85% Anterior Circulation––1515--20% Posterior/Vertebral20% Posterior/Vertebral
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ACOMM ACOMM AnuerysmAnuerysm
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
AneurysmAneurysm
Round (Round (‘‘berryberry’’) shape) shapeVessel bifurcationVessel bifurcation–– natural weaknessnatural weakness–– exploited by high BPexploited by high BP
Common sites:Common sites:–– ACA <ACA <--> ACOMM> ACOMM–– MCA branchesMCA branches–– Basilar TipBasilar Tip
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Angiography Angiography -- AngiogramAngiogram
AP
Oblique
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ICA AneurysmICA Aneurysm
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Bilateral Carotid AneurysmsBilateral Carotid Aneurysms
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Pulsation Artifact
Phase-encoding direction
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ICA AneurysmICA Aneurysm
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Superficial SiderosisSuperficial Siderosis
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Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– MetastaticMetastatic–– PrimaryPrimaryInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– MetastaticMetastatic
Lung, Breast, Renal, Melanoma, Lung, Breast, Renal, Melanoma, ChoriocarcinomaChoriocarcinoma
InfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hemorrhagic MetastasesHemorrhagic Metastases
Hemorrhagic Melanoma Metastasis
Melanoma Metastasis
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Mets: Distributed by BloodMets: Distributed by Blood
Greatest Blood FlowGreatest Blood Flow–– supratentorialsupratentorial–– MCA territoryMCA territory
Greatest FiltrationGreatest Filtration–– GrayGray--White JunctionWhite Junction–– Abrupt Change in Size & Number of Abrupt Change in Size & Number of
VesselsVesselsHematogenous Particles park at vessel branching points …
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Multifocal Multifocal NodularNodular LesionsLesions
All Near Gray matter: cortex and basal ganglia
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Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplastic–– PrimaryPrimary
GBM, Oligodendroglioma, Pituitary, CNC, PCNSLGBM, Oligodendroglioma, Pituitary, CNC, PCNSL
InfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations
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6/157/22
Courtesy of R.D. Zimmerman, NY
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OligodendrogliomaOligodendroglioma
Spontaneous Hemorrhage from fine vesselsSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Oligodendroglioma Oligodendroglioma -- BleedBleed
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Pituitary MACROPituitary MACRO--AdenomaAdenoma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
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Pituitary AdenomaPituitary AdenomaAdult PatientAdult PatientMicroadenomaMicroadenoma–– < 10 mm< 10 mm–– entirely within glandentirely within gland–– Endocrine Sx.Endocrine Sx.
Prolactinoma Prolactinoma AcromegalyAcromegalyGigantismGigantismCushing DiseaseCushing Disease
MacroadenomaMacroadenoma–– > 10 mm> 10 mm–– balloon sellaballoon sella–– Visual SxVisual Sx
if >6 mm above sellaif >6 mm above sellabitemporal hemianopsiabitemporal hemianopsia Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Pituitary ApoplexyPituitary ApoplexyMet Hemoglobin in
Pituitary Macroadenoma
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Met Hemoglobin in Pituitary
Macroadenoma
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David and GoliathDavid and GoliathDid Goliath have Gigantism and/or Did Goliath have Gigantism and/or Acromegaly?Acromegaly?He was a He was a ““GiantGiant””He was an Angry Giant from HA and ICPHe was an Angry Giant from HA and ICPDid he have a Macroadenoma?Did he have a Macroadenoma?–– David was able to sneak up to himDavid was able to sneak up to him
bitemporal hemianopsiabitemporal hemianopsia““Tunnel VisionTunnel Vision””
–– One stone to the head killed himOne stone to the head killed himPituitary ApoplexyPituitary ApoplexyHemorrhage into a macroadenomaHemorrhage into a macroadenoma Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Neoplasms w/HemorrhageNeoplasms w/Hemorrhage
GlioblastomaGlioblastomaOligodendrogliomaOligodendrogliomaPituitary AdenomaPituitary AdenomaCentral NeurocytomaCentral NeurocytomaMetastasesMetastases–– Lung, Breast, Renal, Melanoma, Thyroid, Lung, Breast, Renal, Melanoma, Thyroid,
ChoriocarcinomaChoriocarcinoma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectious–– Necrotizing Encephalitis (Herpes Simplex)Necrotizing Encephalitis (Herpes Simplex)–– AngioinvasiveAngioinvasive Organism (Organism (aspergillusaspergillus, , mucormucor))–– MycoticMycotic AneurysmAneurysm
VasculopathyVasculopathyVascular MalformationsVascular Malformations
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
HSV EncephalitisHSV Encephalitis
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Hemorrhagic Necrosis and AtrophyHemorrhagic Necrosis and Atrophy
PetechialHemorrhages
PetechialHemorrhages
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Serpentine Serpentine -- Cortical GyralCortical Gyral
Encephalitis Meningo-EncephalitisMeningitis
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HSV Encephalitis HSV Encephalitis -- FLAIRFLAIR
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HSV Encephalitis HSV Encephalitis –– T1WGd+T1WGd+
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HSV Encephalitis HSV Encephalitis –– T2WT2W
Hemosiderin
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HSV Encephalitis HSV Encephalitis –– T1WGd+T1WGd+
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HSV Encephalitis HSV Encephalitis –– T1WT1W
Met Hemoglobin in Cortical Petechial
Hemorrhages
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AngioinvasiveAngioinvasive InfectionsInfections
Usually immune suppressedUsually immune suppressed–– AIDSAIDS–– Chronic Diseases (Diabetes)Chronic Diseases (Diabetes)
Organism causes thrombosis, or breaks Organism causes thrombosis, or breaks down vessel walls, causing hemorrhagedown vessel walls, causing hemorrhageTypical fungal organismsTypical fungal organisms–– AspergillusAspergillus: : fumigatusfumigatus (highly aerobic mold)(highly aerobic mold)–– ZygomycetesZygomycetes: e.g. : e.g. MucormycosisMucormycosis
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MucormycosisMucormycosis BG Infarction BG Infarction with Secondary Hemorrhagewith Secondary Hemorrhage
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Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathy–– Hypertension, Hypertension, AmyloidAmyloid, Atherosclerosis, , Atherosclerosis,
Dissection, Autoimmune, InfarctionDissection, Autoimmune, Infarction
Vascular MalformationsVascular Malformations
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Hemorrhagic Embolic InfarctionHemorrhagic Embolic Infarctionvs.vs.
Hemorrhagic ConversionHemorrhagic Conversionvs.vs.
Venous InfarctionVenous Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
CEREBROVASCULAR DISEASE:CEREBROVASCULAR DISEASE:““Hemorrhagic InfarctionHemorrhagic Infarction””
ARTERIAL ETIOLOGYARTERIAL ETIOLOGY–– Embolic Occlusion (MCA)Embolic Occlusion (MCA)–– Herniation (PCA, Herniation (PCA, AChoAAChoA))VENOUS ETIOLOGYVENOUS ETIOLOGY–– Sinus Thrombosis (SSST)Sinus Thrombosis (SSST)–– Deep infarcts in strips, parallel falxDeep infarcts in strips, parallel falxCONVERSION in ISCHEMIC INFARCTCONVERSION in ISCHEMIC INFARCT–– Large Infarcts (whole MCA)Large Infarcts (whole MCA)--Anticoagulation (incl. ASA and Anticoagulation (incl. ASA and thrombolysisthrombolysis))
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Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008NCT
Reperfusion InjuryReperfusion Injury
ECTHemorrhagic Infarction
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Hemorrhagic InfarctionHemorrhagic Infarction
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Hemorrhagic InfarctionHemorrhagic Infarction
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Herniation and PCA InfarctionHerniation and PCA Infarction
Superior Cerebellar a.Superior Cerebellar a.OculomotorOculomotor nerve (CN3)nerve (CN3)TrochlearTrochlear nerve (CN4)nerve (CN4)Posterior Cerebral Posterior Cerebral aaaa..Temporal Lobe HerniationTemporal Lobe Herniation–– Compresses CN3/4Compresses CN3/4–– Compresses PCACompresses PCA
Slow flow allows bleedingSlow flow allows bleeding
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
PCA Infarct Tentorial HerniationPCA Infarct Tentorial Herniation
Courtesy Mauricio Castillo, M.D. UNC
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PCA Infarct from HerniationPCA Infarct from HerniationAnterior ChoroidalArtery Infarction
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Anterior ChoroidalArtery Infarction
Contusion vs. Hemorrhagic InfarctionContusion vs. Hemorrhagic Infarction
Cortical Gray to Depth of SulcusPCA Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Plain T1W MRPlain T1W MR
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
T1W PD
Hemorrhagic InfarctionHemorrhagic Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
PD T2W
Hemorrhagic InfarctionHemorrhagic Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Normal vs. Venous Outflow Normal vs. Venous Outflow ObstObst..
Deoxygenated blood
Stagnates in capillary bed
22
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
MR Imaging of HemorrhageMR Imaging of HemorrhageBlood Product:Blood Product: T1WT1W T2WT2WOxyhemoglobinOxyhemoglobin IsoIso IsoIsoDeDe--oxy Hgboxy Hgb IsoIso (1(1--3hr)3hr) LowLow (2hr)(2hr)
MetMet--Hgb (in cells)Hgb (in cells) HiHi (3(3--14hr)14hr) LowLow
MetMet--Hgb (in soln.) Hgb (in soln.) HiHi HiHi (hrs(hrs--wks)wks)
HemichromesHemichromes LowLow LowLowHemosiderinHemosiderin LowLow LowerLower Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hemorrhagic transformationHemorrhagic transformation
Initial CT 24 hours laterInitial CT 24 hours laterHerniation PCA compression & Bilateral Occipital Infarcts
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Carotid Thrombosis => Carotid Thrombosis => MCA ClotMCA Clot
MCAACA
MCA
PCA
X
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
medpix20366.jpgThis 53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body weakness
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
medpix20367.jpg
Repeat CT scans, two hours after admissionSmirniotopoulos Smirniotopoulos -- USU USU -- 20082008
medpix20375.jpg
DWI ADC Map
ALWAYS compare w/ADC MapALWAYS compare w/ADC Map
23
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Two days after IA Thrombolysis
Thrombotic Cerebral InfarctionThrombotic Cerebral Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Venous Thrombosis and InfarctionVenous Thrombosis and Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
T2W
CT @ 20º MR @ 0º
CTDeep hemorrhage into dead white-mater may spare cortex
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Superior Sagittal Sinus ThrombosisSuperior Sagittal Sinus Thrombosis
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Superior Sagittal Sinus Superior Sagittal Sinus ThrombosisThrombosis
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Sup. Sag. Sinus ThrombosisSup. Sag. Sinus Thrombosis
DehydrationDehydrationParaneoplastic Syndromes w/hypercoagParaneoplastic Syndromes w/hypercoagSpinal AnesthesiaSpinal AnesthesiaPostPost--partumpartum
24
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
CEREBROVASCULAR DISEASE:CEREBROVASCULAR DISEASE:HYPERTENSIONHYPERTENSION
Hypertensive Hematoma (Hemorrhage)Hypertensive Hematoma (Hemorrhage)Lacunar InfarctionLacunar Infarction
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
•Spontaneous Arteriolar Occlusion-lacunar infarcts
•Spontaneous Rupture-”hypertensive hemorrhage”
•Ectatic Elongation-Etat Crible
CEREBROVASCULAR DISEASEArteriolar Sclerosis
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ARTERIOLOSCLEROSISARTERIOLOSCLEROSIS
Hyaline arteriolosclerosisHyaline arteriolosclerosisHyperplastic arteriolosclerosisHyperplastic arteriolosclerosis"Lipohyalinosis""Lipohyalinosis"
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
HYPERTENSIVE CVDHYPERTENSIVE CVD
Arteriolar occlusion Arteriolar occlusion -- ischemiaischemia(Lacunae, Binswanger)(Lacunae, Binswanger)Arteriolar rupture Arteriolar rupture -- hemorrhagehemorrhage(Hematoma(Hematoma--BG, Thal., etc.)BG, Thal., etc.)Etat Crible (Dilated VEtat Crible (Dilated V--R)R)(status cribrosus/cribalis)(status cribrosus/cribalis)
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
CEREBROVASCULAR DISEASECEREBROVASCULAR DISEASEArteriolar SclerosisArteriolar Sclerosis
LACUNAE (Lacunar Infarcts)LACUNAE (Lacunar Infarcts)--MultipleMultiple--Small cavities (1Small cavities (1--15 mm.)15 mm.)--Deep Gray and White:Deep Gray and White:PutamenPutamen, Thalamus, Internal , Thalamus, Internal Capsule, PonsCapsule, PonsPure Motor Pure Motor HemiplegiaHemiplegiaArteriolosclerosis (HT)Arteriolosclerosis (HT)
25
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
ARTERIOLOSCLEROSISARTERIOLOSCLEROSIS
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Old Old LacunarLacunar Infarcts in GPInfarcts in GP
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
HT HEMORRHAGEHT HEMORRHAGE
PutamenPutamen 55%55%CerebrumCerebrum 15%15%ThalamusThalamus 10%10%Pons Pons 10%10%CerebellumCerebellum 10%10%
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
HT BLEEDHT BLEED
Ateriolar SclerosisAteriolar Sclerosis–– Hyaline arteriolosclerosisHyaline arteriolosclerosis–– HyperplasticHyperplastic arteriolosclerosisarteriolosclerosis–– ""LipohyalinosisLipohyalinosis""Penetrating and nonPenetrating and non--anastomoticanastomoticendend--arteries and arteriolesarteries and arteriolesDeep Gray (Nuclear) AreasDeep Gray (Nuclear) Areas
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HemorrhageHypertensive Hemorrhage
BP on presentation 185/105
Courtesy Doug Phillips, UVA
26
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
INTRAINTRA--CEREBRAL CEREBRAL HEMORRHAGEHEMORRHAGE
Dense and HomogeneousDense and HomogeneousRound/oval shapeRound/oval shapeBasal ganglia/deep whiteBasal ganglia/deep whiteProportional mass effectProportional mass effectExtension into ventricleExtension into ventricle
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HemorrhageHypertensive Hemorrhage
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HemorrhageHypertensive Hemorrhage
Usually single eventUsually single eventHA, Pure motor HA, Pure motor hemiplegiahemiplegia, etc., etc.Expanding clot will displace white matterExpanding clot will displace white matterLocal tissue pressure Local tissue pressure tamponadetamponade stops bleedingstops bleedingTreatment is often supportiveTreatment is often supportive–– Herniation and deterioration prompt surgeryHerniation and deterioration prompt surgery
Clot liquefies and is largely absorbedClot liquefies and is largely absorbedHemosiderin ringHemosiderin ring
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HematomaHypertensive Hematoma
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HematomaHypertensive Hematoma
Circumscribed Mass Pushing Margin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
3 mo. p/Hypertensive Hemorrhage3 mo. p/Hypertensive Hemorrhage
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Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
3 mo. p/Hypertensive Hemorrhage3 mo. p/Hypertensive Hemorrhage
Hemosiderin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
3 mo. p/Hypertensive Hemorrhage3 mo. p/Hypertensive Hemorrhage
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
3 mo. p/Hypertensive Hemorrhage3 mo. p/Hypertensive Hemorrhage
Hemosiderin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
81 81 y.oy.o. woman BP 200 mm Hg. woman BP 200 mm Hg
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
28
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
6 days p/Hypertensive Bleed6 days p/Hypertensive Bleed
Met Hemoglobin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
6 days p/Hypertensive Bleed6 days p/Hypertensive Bleed
Hemosiderin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
6 days p/Hypertensive Bleed6 days p/Hypertensive Bleed
Met Hemoglobin
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HemorrhageHypertensive Hemorrhage
BP on presentation 210/110
Courtesy Doug Phillips, UVA
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hypertensive HemorrhageHypertensive Hemorrhage
Hypertensive “hit list”External CapsuleThalamusDentate NucleusPonsLobar
*
Courtesy Doug Phillips, UVA Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Hemorrhage into a massHemorrhage into a massAcute hemiplegia and confusion in a 68 year old man
Courtesy Doug Phillips, UVA
NOTE: Vasogenic Edema
29
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
GBMGBM
Courtesy Doug Phillips, UVA Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Pt acutely agitatedPt acutely agitatedMass EffectMass Effect
Hypertensive Bleed vs. CCMHypertensive Bleed vs. CCMPt with only HAPt with only HAMinimal mass effectMinimal mass effect
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
CCM Has Complex Blood ProductsCCM Has Complex Blood Products
Minimal mass effect, at presentation, blood products already complex with both methemoglobin (bright) and hemosiderin (dark)
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
AmyloidAmyloid AngiopathyAngiopathy
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Arteriolosclerosis vs. Arteriolosclerosis vs. AmyloidAmyloid
Long standing HTLong standing HTLocation:Location:–– Basal Ganglia, Basal Ganglia,
Thalamus, BrainstemThalamus, Brainstem
Single EventSingle Event
+/+/-- HypertensionHypertensionLocation:Location:–– Usually LobarUsually Lobar–– Often Often MultificalMultifical
Multiple EventsMultiple Events–– Can be bilateralCan be bilateral
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Mar 11 Mar 30
Mar 13
30
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008 Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Extensive Amyloid, Acute BleedExtensive Amyloid, Acute Bleed
MRI - T2* CTCourtesy Howard Rowley, M.D.
31
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Cerebral Cerebral amyloidamyloid angiopathyangiopathy
Extracellular deposition of Extracellular deposition of amyloidamyloid in the walls of in the walls of brain and brain and meningealmeningeal blood vesselsblood vessels17 biochemically distinct forms of 17 biochemically distinct forms of amyloidamyloidBB--APP, APP, CystatinCystatin C, British protein involvedC, British protein involvedAmyloidAmyloid fibrils show fibrils show BB--Pleated sheet Pleated sheet secondary structuresecondary structureStains: Congo red, PAS, Stains: Congo red, PAS, ThyoflavinThyoflavin S or TS or T
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Cerebral Cerebral amyloidamyloid angiopathyangiopathy
Involvement of small arteries and Involvement of small arteries and arterioles of cerebrum, cerebellum and arterioles of cerebrum, cerebellum and leptomeningesleptomeningesPathological changesPathological changes–– FibrinoidFibrinoid necrosisnecrosis–– MicroaneurysmsMicroaneurysms
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Cerebral Cerebral amyloidamyloid angiopathyangiopathy
Alzheimer diseaseAlzheimer diseaseLobar hemorrhageLobar hemorrhage–– SporadicSporadic–– FamilialFamilial
Ischemic infarct in ADIschemic infarct in ADIschemic infarct in nonIschemic infarct in non--demented demented patientspatients
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy Vince Mathews, M.D.
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008Courtesy Vince Mathews, M.D.
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
MicrobleedsMicrobleeds vs. Cavernous Malformationsvs. Cavernous Malformations
Courtesy Vince Mathews, M.D.
“microbleeds” are BLACK … cavernous malformations are complex Black & White
32
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Arteriolosclerosis vs. Arteriolosclerosis vs. AmyloidAmyloid
Long standing HTLong standing HTLocation:Location:–– Basal Ganglia, Basal Ganglia,
Thalamus, BrainstemThalamus, Brainstem
Single EventSingle Event
+/+/-- HypertensionHypertensionLocation:Location:–– Usually LobarUsually Lobar
Often multiple and Often multiple and progressiveprogressive–– Can be bilateralCan be bilateral
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Intracranial HemorrhageIntracranial Hemorrhage
TraumaticTraumaticAneurysmsAneurysmsNeoplasticNeoplasticInfectiousInfectiousVasculopathyVasculopathyVascular MalformationsVascular Malformations–– Covered by Dr. SmithCovered by Dr. Smith
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
SummarySummary
Hemorrhage has many causesHemorrhage has many causesHemorrhage has many locationsHemorrhage has many locationsHemorrhage has a variable appearanceHemorrhage has a variable appearance–– Especially on MRIEspecially on MRI
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Location of HemorrhageLocation of Hemorrhage
Extraaxial Hemorrhage: Epidural – Subdural - Subarachnoid
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Appearance of HemorrhageAppearance of Hemorrhage
Smirniotopoulos Smirniotopoulos -- USU USU -- 20082008
Thank You!Thank You!
Muito Obrigado
EUXAPIΣTΩ !Mahalo !
Dank u wel !Merci Beaucoup
Danke Schön !
Muchas Gracias
Go Raibh Maith Agat
ありがとうございます。感謝いたします。
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