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Neuroimaging in intracerebral hemorrhage management
What neuroimaging modalities should be used in ICH evaluation and management?
Noncontrast computed tomography (CT) head scan
This is the imaging modality of choice to assess for ICH location, volume, ventricular extension, hydrocephalus, and mass effect.
Hematoma volume can be calculated using the ABC/2 formula. A = longest diameter, B = largest diameter perpendicular to A, and C is the number of CT slices with hematoma × thickness of 10-mm slices in cm (if 5 mm divide C by 2).
In most cases a noncontrast CT of the head is the only imaging modality that is required particularly in those patients with ICH located in the basal ganglia and thalamus.
Magnetic resonance imaging (MRI) of the brain
This may be needed to assess for ischemic stroke, underlying tumor, vascular lesion, and prior microbleeds or macrobleeds on gradient echo (GRE) sequence.
Abnormalities in the latter would indicate the presence of cerebral amyloid angiopathy (CAA) (superficial lobar region) or hypertension-related changes (deep subcortical and infratentorial region).
CT angiography (CTA)
This spot sign is an indicator of active hemorrhage, which has been associated with increased risk of hematoma expansion, mortality, and poor outcome.
However, further studies are under way to determine the significance of the spot sign in daily clinical practice.
Vascular imaging:
Noninvasive imaging such as CTA and MR angiogram (MRA) and/or an invasive modality such as digital subtraction angiography (DSA) should be considered in those patients where a vascular abnormality is suspected.
Sources
From Law M, Som P, Naidich T: Problem solving in neuroradiology . Philadelphia, Elsevier, 2011
