MRI: magnetic resonance imaging. From: Flemming KD, Lanzino G. Management of Unruptured Intracranial Aneurysms and Cerebrovascular Malformations. Continuum (Minneap Minn) 2017; 23:181. DOI: 10.1212/CON.0000000000000418. Copyright 2017 American Academy of Neurology. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 53992 Version 6.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 39/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Cerebellar hematoma due to ruptured AVM (A) Noncontrast head CT showing acute right cerebellar ICH with smaller adjacent focus of hemorrhage (black arrow). (B) Subsequent FLAIR sequence on brain MRI after decompressive craniectomy showing flow void (white arrow) adjacent to ICH (white dashed arrow). (C) Digital subtraction angiogram subsequently identified an AVM with a nidus (white arrowhead), feeding artery (white thick arrow), and draining vein (white short arrow). CT: computed tomography; ICH: intracerebral hemorrhage; FLAIR: fluid-attenuated inversion recovery; MRI: magnetic resonance imaging; AVM: arteriovenous malformation. Courtesy of Glenn A Tung, MD, FACR. Graphic 132273 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 40/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Intracerebral hemorrhage due to cerebral sinus thrombosis Noncontrast head CT showing left frontal ICH (arrow) and vasogenic edema (arrowhead) (A). Mid-sagittal plane on CT angiography (B) and MRV (C) showing filling defect (thick arrows) in superior sagittal sinus (B). Subsequent brain MRI with FLAIR (D) and T2* gradient recall echo (E) imaging showing larger ICH (arrows) and associated edema (arrowheads). ICH: intracerebral hemorrhage; CT: computed tomography; MRV: magnetic resonance venography; MRI: magnetic resonance imaging; FLAIR: fluid-attenuated inversion recovery. Courtesy of Glenn A Tung, MD, FACR. Graphic 132274 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 41/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Hemorrhagic transformation of ischemic infarction Noncontrast head CT (A) shows heterogeneous hyperdensity within hypodense region involving right frontal and insular lobes. On subsequent MRI of the brain, FLAIR (B), T2* gradient recall echo (C), and DWI (D) sequences show hypointense ICH (thin arrows) and hyperintensities consistent with acute infarction in the distribution of the right middle cerebral artery (thick arrows). CT: computed tomography; MRI: magnetic resonance imaging; FLAIR: fluid-attenuated inversion recovery; DWI: diffusion-weighted imaging; ICH: intracerebral hemorrhage. Courtesy of Glenn A Tung, MD, FACR. Graphic 132275 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 42/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Brain lesions in reversible cerebral vasoconstriction syndrome Representative brain images from patients with RCVS are shown to highlight different lesion patterns. The numbers in parenthesis show the percentages of the lesion patterns; totals exceed 100% due to lesion combinations. (A) No acute parenchymal lesion (24%). Normal axial DWI, GRE, and FLAIR images are shown. The hyperintense dot sign is present on FLAIR (far right, arrow). (B) Border zone/watershed infarcts (25%). On the far left, DWI shows typical symmetric, posterior infarcts that spare the cortical ribbon. In https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 43/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate the middle and on the far right, DWI shows widespread watershed infarcts. (C) Vasogenic edema (28%). Subcortical crescent-shaped T2- hyperintense lesions consistent with the posterior reversible encephalopathy syndrome are seen on FLAIR. (D) Hemorrhagic lesions (42%). The two images on the left (axial GRE) show simultaneous lobar and deep intraparenchymal hemorrhages. The two images on the right show convexal subarachnoid hemorrhages on CT and axial GRE. (E) Lesion combinations (28%). The two images on the left show bilateral watershed infarcts on DWI and the two images on the right show lobar as well as convexal subarachnoid hemorrhages on axial FLAIR and CT, all in the same patient. RCVS: reversible cerebral vasoconstriction syndrome; DWI: diffusion- weighted images; GRE: gradient-echo; FLAIR: fluid-attenuated inversion recovery; CT: computed tomography. From: Singhal AB, Topcuoglu MA, Fok JW, et al. Reversible cerebral vasoconstriction syndromes and primary angiitis of the central nervous system: clinical, imaging, and angiographic comparison. Ann Neurol 2016; 79:882. http://onlinelibrary.wiley.com/wol1/doi/10.1002/ana.24652/abstract. Copyright 2016 American Neurological Association. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com). Graphic 109962 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 44/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Excessive perihematomal edema in a patient with hemorrhagic lung metastasis Noncontrast head CT showing left frontal ICH surrounded by excessive volume of hypodense vasogenic edema (A, B). MRI performed one day later shows hyperintense vasogenic edema on T2*-weighted gradient echo image (C). Pre- (D) and post-contrast (E) T1-weighted MRI images demonstrate enhancement (arrows) consistent with underlying tumor. CT: computed tomography; ICH: intracerebral hemorrhage; MRI: magnetic resonance imaging. Courtesy of Glenn A Tung, MD, FACR. Graphic 132284 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 45/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Intracerebral hemorrhage due to mycotic aneurysm Noncontrast head CT (A) showing small right parietal ICH (circle). CT angiogram in axial (B) and coronal (C) planes showing small mycotic aneurysm (arrow) adjacent to ICH (circle). CT: computed tomography; ICH: intracerebral hemorrhage. Courtesy of Glenn A Tung, MD, FACR. Graphic 132276 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 46/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate 12-year-old with moyamoya syndrome secondary to neurofibromatosis type 1 Magnetic resonance angiogram shows occlusion of left supraclinoid internal carotid artery (circles) and lentic collateral vessels (arrow). Courtesy of Glenn A Tung, MD, FACR. Graphic 129107 Version 3.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 47/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate 40-year-old with moyamoya disease Digital subtraction angiogram shows stenosis of right supraclinoid carotid, proximal middle cerebral artery a artery (oval), and lenticulostriate moyamoya collateral vessels (arrows). Courtesy of Glenn A Tung, MD, FACR. Graphic 129102 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 48/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Intracerebral hemorrhage with intraventricular hemorrhage due to moyamoya syndrome Noncontrast head CT (A) showing hematoma in the right corpus striatum and lateral ventricles. Digital subtraction angiogram (B) showing critical stenosis of proximal right middle cerebral artery (arrow), prominent collateralization of both lenticulostriate vessels (circle), and branches of the anterior cerebral artery (thick arrows). CT: computed tomography. Courtesy of Glenn A Tung, MD, FACR. Graphic 132277 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 49/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Acute spontaneous intracerebral hemorrhage: Rapid overview of emergency management Clinical features Stroke symptoms: sudden onset loss of function in speech, vision, movement, sensation, balance Features suggestive of ICH over ischemic stroke: progressive worsening of acute symptoms; severely elevated SBP (eg, >220 mmHg); patient taking anticoagulant Signs of elevated ICP (mass effect from ICH): Dilated pupil Progressive drowsiness Cushing triad (bradycardia, respiratory depression, hypertension) Evaluation Assess airway, breathing, circulation, and disability to initiate supportive care Determine GCS, neurologic deficits Obtain emergency imaging (eg, head CT or fast MRI) Initial laboratory evaluation: complete blood count, PT, PTT, INR, basic electrolytes, glucose, cardiac-specific troponin, pregnancy test in females of childbearing age Serial monitoring (hourly) for neurologic deterioration or signs of elevated ICP Treatment* Perform tracheal intubation for any patient unable to protect their airway or with rapidly deteriorating mental status or GCS 8 Obtain immediate neurosurgical consultation for imaging findings indicating need for emergency surgery: 3 Cerebellar ICH that is either 3 cm diameter or causing brainstem compression IVH with obstructive hydrocephalus and neurologic deterioration Hemispheric ICH with life-threatening brain compression or obstructive hydrocephalus Reverse anticoagulation (agent specific): Warfarin (4-factor PCC with IV vitamin K) Dabigatran (idaricizumab) https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 50/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Factor Xa inhibitors: apixaban, edoxaban, rivaroxaban (4-factor PCC or andexanet alfa) Unfractionated heparin (protamine sulfate) Low molecular weight heparin (andexanet alfa; protamine sulfate is an alternative) Manage hypertension: Immediate treatment to reduce SBP below 220 mmHg: nicardipine starting at 5 mg/hour IV; alternate: labetalol 20 mg IV bolus, may repeat every 10 minutes Subsequent, stepwise treatment, typically over first 1 to 2 hours, to reduce SBP to 140 to 160 mmHg; monitor for neurologic deterioration Manage elevated intracranial pressure: General preventive measures: Elevate head of bed >30 degrees Give mild sedation as needed for comfort for intubated patients (eg, midazolam) Give antipyretics for temperature >38 C (eg, acetaminophen [paracetamol] 325 to 650 mg orally or PR every 4 to 6 hours or 650 mg IV every 4 hours) Maintain neutral head positioning; avoid rotating the neck or placing IV lines or devices in or at the neck that may impede venous outflow Use isotonic solutions for volume resuscitation and maintenance fluids; maintain serum sodium >135 mEq/L Repeat imaging (eg, head CT) for neurologic deterioration or signs of elevated ICP: Obtain immediate neurosurgical consultation for surgical indications (refer to above) Give osmotic therapy via central venous catheter for clinical signs or imaging findings of elevated ICP: Hypertonic saline 23.4%: 15 to 30 mL IV bolus every 6 hours, or Mannitol: 0.25 to 1 g/kg IV bolus every 6 hours ICH: intracerebral hemorrhage; SBP: systolic blood pressure; ICP: intracranial pressure; GCS: Glasgow coma scale; CT: computed tomography; MRI: magnetic resonance imaging; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; IVH: intraventricular hemorrhage; PCC: prothrombin complex concentrate; IV: intravenous; PR: per rectum. Treatment steps for the acute management of ICH may be performed in parallel if resources are available. Graphic 132288 Version 5.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 51/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Time course of neurologic changes in intracerebral hemorrhage Schematic representation of rapid downhill course in terms of unusual behavior (solid line), hemimotor function (dotted line), and consciousness (dash-dotted line) in a patient with intracerebral (intraparenchymal) hemorrhage. Graphic 61491 Version 3.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 52/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Headache and vomiting in stroke subtypes The frequency of sentinel headache, onset headache, and vomiting in three subtypes of stroke: subarachnoid hemorrhage, intraparenchymal (intracerebral) hemorrhage, and ischemic stroke. Onset headache was present in virtually all patients with SAH and about one-half of those with IPH; all of these symptoms were infrequent in patients with IS. SAH: subarachnoid hemorrhage; IPH: intraparenchymal (intracerebral) hemorrhage; IS: ischemic stroke. Data from: Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986; 36:1445. Graphic 60831 Version 4.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 53/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate CT and MRI scans of hyperacute intracerebral hemorrhage CT and MRI studies were obtained less than six hours from symptom onset in a patient with spontaneous acute intracerebral hemorrhage. The CT scan shows a hyperdense hemorrhage predominantly in the left frontal lobe. On MRI, the central portion of the hematoma is isointense to brain parenchyma on the T1-weighted image and hyperintense on the T2-weighted and T2* gradient echo images, consistent with hemorrhage containing oxyhemoglobin. On the T2-weighted and T2* gradient echo images, the periphery of the hemorrhage is hypointense, consistent with deoxygenation that occurs more rapidly at the borders. On the T2 weighted image, tissue adjacent to and surrounding the hematoma is hyperintense, consistent with vasogenic edema. CT: computed tomography; MRI: magnetic resonance imaging; ICH: https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 54/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate intracerebral hemorrhage. Graphic 81767 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 55/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Evolution of intracerebral hemorrhage on head CT over time Noncontrast head CT (A-F) of putaminal ICH with IVH showing typical reduced centripetal density and size over time. Imaging performed at days 1 (A), 14 (B), 19 (C), 24 (D), 40 (E), and 50 (F). ICH: intracerebral hemorrhage; CT: computed tomography; IVH: intraventricular hemorrhage. Courtesy of Glenn A Tung, MD, FACR. Graphic 132278 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 56/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Temporal evolution of intracerebral hematoma on MRI Hemoglobin Descriptor Approximate age T1 T2 moiety iso or Hyperacute Oxy <3 hours iso or Acute Deoxy <3 days Early subacute Intracellular met 3 to 13 days Late subacute Extracellular met <3 weeks iso or Chronic Hemosiderin/ferritin >3 weeks MRI: magnetic resonance imaging; T1: T1-weighted sequence; T2: T2-weighted sequence; oxy: oxyhemoglobin; iso: isointense or same signal intensity as brain; : hypointense compared with normal brain; : hyperintense compared with normal brain; deoxy: deoxyhemoglobin; met: methemoglobin. Courtesy of Glenn A Tung, MD, FACR. Graphic 132279 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 57/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Clinical and neuroimaging features of intracerebral hemorrhage associated with underlying causes Alternative Specifying ICH Characteristic Other associated features underlying feature underlying cause causes Basal ganglia or Deep perforating CMBs in basal ganglia, thalamus, pons, cerebellar brainstem location vasculopathy (HTN) nuclei Subcortical white matter lesions on MRI Deep perforating territory ischemic infarcts Clinical history of HTN or diabetes mellitus Lobar location Cerebral amyloid angiopathy Deep penetrating vasculopathy (HTN) Cortico-subcortical CMBs Convexal superficial siderosis Clinical history of cognitive impairment Intraventricular hemorrhage Arteriovenous malformation Deep penetrating vasculopathy (HTN) Flow voids within or adjacent to ICH Calcification within or adjacent to ICH Cavernous malformation Small ICH with adjacent calcification Cavernous malformation Deep penetrating vasculopathy (HTN) T2-weighted image hyperintensity at center on MRI Peripheral rim of T2*- weighted gradient echo image hypointensity on MRI Subarachnoid Ruptured cerebral Perimesencephalic SAH predominates over basal surfaces hemorrhage Basal cisterns aneurysm hemorrhage Clinical history of Non-aneurysmal SAH thunderclap headache Subarachnoid hemorrhage Reversible cerebral vasoconstriction Trauma Hemispheric or cortical ICH Clinical history of recurrent thunderclap headache Cerebral amyloid Convexity syndrome angiopathy Cerebral venous thrombosis https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 58/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Arteriovenous malformation Simultaneous Infective endocarditis Cerebral amyloid CMBs acute infarcts angiopathy Mycotic aneurysms (typically distal arterial locations) Deep penetrating vasculopathy (HTN) Systemic/cutaneous evidence of embolism New heart murmur Cerebral vasculitis Multifocal segmental narrowing on vascular imaging Clinical history of new persistent headaches Progressive cognitive or other neurologic impairment Prominent edema Cerebral sinus thrombosis Subacute ICH of other etiologies Edema/hemorrhage extends to cortical surface Venous flow void (eg, delta and empty-delta signs) Clinical history of seizure or progressive headache Tumor (primary/metastatic) Multifocal lesions Contrast enhancement Clinical history of new persistent headaches Clinical exam findings may be milder than imaging abnormalities Hemorrhagic transformation of (Cytotoxic) Edema appears in distribution of arterial territory infarct Arterial stenosis or occlusion proximal to territory of hemorrhage Clinical history of ischemic risk factors Flow voids Moyamoya Arteriovenous malformation Basal ganglia or hemispheric location Bilateral (but may be asymmetric) narrowing of distal internal carotid or https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 59/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate proximal anterior/middle cerebral arteries Clinical history of episodes of transient weakness with vigorous laughing/crying (Prominent cause of ICH and infarcts in children) ICH: intracerebral hemorrhage; HTN: hypertension; CMB: cerebral microbleeds; MRI: magnetic resonance imaging; SAH: subarachnoid hemorrhage. Graphic 132289 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 60/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Restricted diffusion associated with acute ICH Axial diffusion-weighted image (DWI) on brain MRI (A) and corresponding apparent diffusion coefficient (ADC image (B) showing hyperintense DWI and hypointense ADC foci (arrows) suggestive of acute ischemia associ with acute ICH (arrowheads). ICH: intracerebral hemorrhage; MRI: magnetic resonance imaging. Courtesy of Scott A Kasner, MD. Graphic 141459 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 61/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate ABC/2 method for estimating intracerebral hemorrhage volume Acute left basal ganglia hemorrhage measured by the ABC/2 method. A is 6 cm, B is 4 cm, and C is 3 cm (hematoma is seen on 12 slices [10 full and 4 half] with a slice thickness of 0.25 cm). Hematoma volume is 36 cc ([6 4 3]/2). rd Reproduced from: Thabet AM, Kottapally M, Hemphill JC 3 . Management of intracerebral hemorrhage. Handb Clin Neurol 2017; 140:177. Illustration used with the permission of Elsevier Inc. All rights reserved. Graphic 118213 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 62/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate CT angiography "spot sign" Patient with spot sign, demonstrating extravasation and hematoma expansion. CT slice selection has been optimized for hematoma configuration, not for head position. (A) Unenhanced CT demonstrates left posterior putaminal and internal capsule hematoma with mild surrounding edema. An old parieto-occipital infarct is seen posterior to this. (B) A small focus of enhancement is seen peripherally on CTA source images, consistent with the spot sign (arrow). https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 63/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate (C) Post-contrast CT demonstrates enlargement of the spot sign, consistent with extravasation (thick arrow). (D) Unenhanced CT image one day after presentation reveals hematoma enlargement and intraventricular hemorrhage. CT: computed tomography; CTA: computed tomography angiography. From: Wada R, Aviv RI, Fox AJ, et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007; 38:1257. Copyright 2007 American Heart Association, Inc. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 118220 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 64/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate ICH features on head CT associated with the risk of hematoma expansion Noncontrast head CT showing acute ICH with signs associated with the risk of subsequent hematoma expansion: irregular shape (A), island sign (B; arrow), hypodensity (C; dashed arrow), heterogeneity (D), black hole sign (E; thick arrow), swirl sign (F), and blend sign (G; arrowhead). ICH: intracerebral hemorrhage; CT: computed tomography. Courtesy of Glenn A Tung, MD, FACR. Graphic 132280 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 65/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Multifocal intracerebral hemorrhage from thyroid cancer Noncontrast head CT (A) shows multiple hyperdensities (arrows). T2*-weighted gradient echo MRI images show that some but not all lesions are hypointense hemorrhages (B, C). Pre- (D) and post-contrast (E) T1- weighted MRI images show contrast enhancement consistent with metastases. ICH: intracerebral hemorrhage; CT: computed tomography; MRI: magnetic resonance imaging. Courtesy of Glenn A Tung, MD, FACR. Graphic 132287 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 66/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Intraventricular hemorrhage due to ruptured periventricular arteriovenous malformation Noncontrast head CT (A) showing IVH. CT angiogram (B) showing abnormal tangle of vessels (circle) in the left perisplenial region. Digital subtraction angiogram (C) showing AVM nidus (circle). CT: computed tomography; IVH: intraventricular hemorrhage; AVM: arteriovenous malformation. Courtesy of Glenn A Tung, MD, FACR. Graphic 132281 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 67/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Evaluating the underlying etiology of nontraumatic intracerebral hemorrhage This is an algorithm to guide etiologic testing; additional testing may be indicated for patients who develop new or worsening symptoms during recovery period. Refer to the UpToDate topic on secondary prevention and long-term prognosis of spontaneous intracerebral hemorrhage for additional details. ICH: intracerebral hemorrhage. Refer to the separate UpToDate table on clinical and neuroimaging features of intracerebral hemorrhage associated with underlying causes. Lobar or cortical ICH, evidence of multifocal superficial siderosis, age 55 years, and other sources for hemorrhagic features excluded. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 68/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Refer to the UpToDate topic on cerebral amyloid angiopathy for additional details. Graphic 132295 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 69/70 7/5/23, 12:25 PM Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis - UpToDate Contributor Disclosures Guy Rordorf, MD No relevant financial relationship(s) with ineligible companies to disclose. Colin McDonald, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Jonathan A Edlow, MD, FACEP No relevant financial relationship(s) with ineligible companies to disclose. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator-initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Glenn A Tung, MD, FACR No relevant financial relationship(s) with ineligible companies to disclose. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-pathogenesis-clinical-features-and-diagnosis/print 70/70