Intracranial Hemorrhage: Amyloid Angiopathy, Vascular Lesions, and Neoplasms

00:01 Now, let’s talk about amyloid angiopathy. This is a third category or cause of an intraparenchymal hemorrhage. And here we see the typical imaging presentation. This is a patient who has suffered multiple lobar hemorrhages in the brain over time. You can see the area of hemorrhage is out in the lobes of the brain which is very different from the location of the hypertensive hemorrhages and some hemorrhagic transformations of ischemic infarcts. On the non-contrast head CT on the left, we see multiple areas of hemorrhage. One new hemorrhage in the anterior right frontal lobe and a little bit of hemorrhage behind that that looked more acute and then an area of subacute, perhaps early or late subacute blood in the right posterior frontal lobe. On the next two sequences, we’re looking at susceptibility way to damages, which highlight area of hemorrhage and we see new hemorrhage in the right frontal lobe, a subacute hemorrhage in the posterior aspect of the occipital regions, and on the far right image, these small areas of micro hemorrhage which are highly suspicious, and in some cases diagnostic of a diagnosis of amyloid angiography. So, the combination of lobar hemorrhage and in multiple micro hemorrhages should raise high suspicion for this diagnosis in patients presenting with new intraparenchymal or intracranial hemorrhage. Now, let’s talk about vascular lesions. This is our fourth category or cause of an intraparenchymal hemorrhage, and here we’re looking at a patient who has had a previously intervened vascular malformation presenting with new hemorrhage.

01:34 This is a patient who had a prior clipping and you can see the artifact on the far left CT from a clipping of a prior AVM who presented with new focal neurologic deficits, had CT of the head that showed this area of new blood, hyperdensity in that same area of AVM. The CT scan on the left and in the middle demonstrate that area of hemorrhage and the catheter angiogram that you see on the far right shows this area of blush of blood which is a connection between the arteries and veins and arteriovenous malformation which increases the risk of hemorrhage within the brain. And then our last or fifth category of causes of intraparenchymal hemorrhage are neoplasms. So, we can see bleeding from brain metastases, secondary brain tumors and primary brain tumors, typically those that are more malignant. This patient presented with new focal neurologic deficits and was found to have this right hemispheric hemorrhage with left hemibody symptoms. On the head CT to the left, you can see a small focus of hemorrhage, a very small hemorrhage but a large area of edema around that, which raises suspicion that this hemorrhage may be occurring from an underlying lesion and that's what’s causing the swelling and the hemorrhage. An MRI was subsequently performed, and you can see that in the middle and right side of the screen. In the middle, we see the T2 lesion showing an underlying lesion with a large area of surrounding edema and mass effect as well as some early midline shift. And then on the far right, the susceptibility weighted image shows an internal area of hemorrhage but a larger area of deficit around that which is highly suggestive of an underlying tumor.