10 May Disclosure. + Outline. Case-based approach to nontraumatic intracranial hemorrhage. Kathleen R. Fink, MD University of Washington

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1 Kathleen R. Fink, MD University of Washington 5 th Nordic Emergency Radiology Course May 21, 2015 Disclosure My spouse receives research salary support from: Bracco BayerHealthcare Guerbet Outline Case-based approach to nontraumatic intracranial hemorrhage 1. Subarachnoid hemorrhage 2. Intraventricular hemorrhage 3. Lobar intraparenchymal hemorrhage 4. Deep Intraparenchymal hemorrhage 1

Scenario 1 Subarachnoid hemorrhage Thunderclap HA,

spontaneous SAH DSA is the gold standard of diagnosis,

* Evidence-Based Neuroimaging Diagnosis and Treatment,

2 Scenario 1 Subarachnoid hemorrhage Thunderclap HA, collapse Aneurysmal SAH Aneurysms account for 85% of spontaneous SAH DSA is the gold standard of diagnosis, but CTA is almost equivalent and readily available*. * Evidence-Based Neuroimaging Diagnosis and Treatment, Editors LS Medina, PC Sanelli, and JG Jarvik. Springer

Worst headache of life CT Angiogram and DSA negative

Blood centered immediately anterior to midbrain or pons.

Sylvian and interhemispheric fissures. Cannot extend distally.

these patients, although DSA is often obtained*.

3 Worst headache of life CT Angiogram and DSA negative Non-aneurysmal Perimesencephalic Hemorrhage 10-15% of spontaneous SAH. Definition: On NECT within 3 days of symptom onset: 1. Blood centered immediately anterior to midbrain or pons. Involves basilar cisterns: interpeduncular, crural, ambient, quadrigeminal, prepontine or carotid 2. May extend into suprasellar cistern and basal portions of Sylvian and interhemispheric fissures. Cannot extend distally. 3. Small blood layering in occipital horns of lateral ventricles, but no frank IVH. Limited evidence indicates CTA alone may be sufficient in these patients, although DSA is often obtained*. van Gijn Neurology 1985;35(4): * Evidence-Based Neuroimaging Diagnosis and Treatment, Editors LS Medina, PC Sanelli, and JG Jarvik. Springer year old woman, thunderclap HA while swimming in hot springs 3

56 year old woman, thunderclap HA while swimming in hot springs Day 1 Day 5

young and middle-aged women with severe, recurrent headaches Triggers Drugs

Peripartum, eclampsia Strenuous physical activity Bathing/showering Findings

delayed fashion (as in this case) Hallmark is resolution of vasoconstriction

4 56 year old woman, thunderclap HA while swimming in hot springs Day 1 Day 5 RCVS: Reversible Cerebral Vasoconstriction Syndrome Clinical: Predominantly young and middle-aged women with severe, recurrent headaches Triggers Drugs (amphetamines, serotonergic antidepressants, nicotine, caffeine, etc) Peripartum, eclampsia Strenuous physical activity Bathing/showering Findings Segmental vasoconstriction, multiple vessels Abnormalities may develop in a delayed fashion (as in this case) Hallmark is resolution of vasoconstriction with supportive treatment and removal of trigger Headache, hemiparesis, seizure Noncontrast CT 4

Cortical venous thrombosis Hyperdense cord sign on noncontrast CT due to acute thrombosis

CT venogram 76 year old with hemiparesis and aphasia Ddx: Cerebral amyloid angiopathy Lobar

Boston Criteria: Definite CAA: postmortem exam Probable with pathology: Lobar, cortical or

restricted to lobar, cortical, or corticosubcortial regions Age > 55 No other cause of

5 Cortical venous thrombosis Hyperdense cord sign on noncontrast CT due to acute thrombosis Concomitant filling defect in cortical vein and superior sagittal sinus on CT venogram. CT venogram 76 year old with hemiparesis and aphasia Ddx: Cerebral amyloid angiopathy Lobar hemorrhages SAH in older person. Boston Criteria: Definite CAA: postmortem exam Probable with pathology: Lobar, cortical or cortical/subcortical hemorrhage Path specimen with CAA Probable: Multiple hemorrhages restricted to lobar, cortical, or corticosubcortial regions Age > 55 No other cause of hemorrhage identified Possible: Single lobar, cortical, or corticalsubcortical hemorrhage Age > 55 years No other cause of hemorrhage Knudsen Neurology 2001;56(4): : T2* GRE 5

6 Scenario 1: Subarachnoid hemorrhage Diffuse or perimesencephalic Trauma Saccular aneurysm Perimesencephalic hemorrhage Nonsaccular aneurysm (fusiform, dissecting) Arterial Dissection Vascular malformation AVM Dural AVF Tumor Vasculopathy RCVS Vasculitis Convexity RCVS Cerebral amyloid angiopathy PRES Cerebral venous thrombosis Septic emboli Septic aneurysm Coagulopathy Moyamoya Superficial vascular malformation Tumor Vasculitis Marder AJR Am J Roentgenol 2014;202(1): Scenario 1: Subarachnoid hemorrhage Marder AJR Am J Roentgenol 2014;202(1): Scenario 2 Intraventricular hemorrhage 6

7 64 yo, loss of consciousness 7

8 Arteriovenous malformation 64 years old, slightly old for primary presentation AVMs: Most common cause of ICH in patients < 40 years Peak age: Only 5% of AVMs present > 60 years old But we must find them! 50 year old, loss of consciousness 50 year old, loss of consciousness 8

50 year old, loss of consciousness Moyamoya Supraclinoid ICA

Puff of smoke vessels tortuous lenticulostriate collaterals

Sickle cell anemia Atherosclerosis Radiation Scenario 2:

9 50 year old, loss of consciousness Moyamoya Supraclinoid ICA occlusion Vertebrobasilar system usually spared. Puff of smoke vessels tortuous lenticulostriate collaterals Etiology: Primary Secondary Downs syndrome Tuberous sclerosis Sickle cell anemia Atherosclerosis Radiation Scenario 2: Intraventricular hemorrhage Differential diagnosis: Unknown/idiopathic 50% AVM Aneurysm Moya moya Dural AVF 9

10 Scenario 3 Deep hemorrhage 46 year old man with sudden severe HA T2* GRE 10

lacunar infarctions Hypertensive hemorrhage Location (Small perforating arterioles): Basal ganglia/external capsule

11 Hypertensive hemorrhage Classic location Appropriate clinical history (hypertension) Rule out other causes in younger/middle aged person Deep microhemorrhages on T2* GRE confirmatory finding May see chronic ischemic disease and/or lacunar infarctions Hypertensive hemorrhage Location (Small perforating arterioles): Basal ganglia/external capsule Thalamus 75% Pons Cerebellum 15% Centrum semiovale Rupture of Charcot-Bouchard microaneuryms possible cause 51 year old, HA T1 T2 T1 Post 11

T2* GRE Thalamic cavernous malformation Cavernous

12 T2* GRE Thalamic cavernous malformation Cavernous hemangioma, cavernoma POP! Multiple areas of hemosiderin deposition, different sizes Popcorn appearance, bright T1 and T2 areas. Cavernoma, no acute hemorrhage Note DVA! NECT CT with contrast 12

Cavernoma 2-3% of ICH 15% of ICH in patients < 40 years old Supratentorial (60%) > Infratentorial (40%) Pons a common infratentorial location Think cavernoma with hemorrhage if: Small hematoma (< 3

13 Cavernoma 2-3% of ICH 15% of ICH in patients < 40 years old Supratentorial (60%) > Infratentorial (40%) Pons a common infratentorial location Think cavernoma with hemorrhage if: Small hematoma (< 3 cm) Calcification (20%) Associated DVA Scenario 3: Deep hemorrhage Differential diagnosis: Hypertension! Others: Cavernous malformation AVM (especially if younger) Moyamoya Vein of Galen occlusion (rare) Trauma/DAI Scenario 4 Lobar hemorrhage 13

14 76 year old woman: redux T2 T1 T1 Post T2* GRE 14

15 Amyloid angiopathy Lobar hemorrhage Subarachnoid hemorrhage (can present as isolated SAH) Older person (>60-70) T2* imaging helpful for additional microhemorrhages at graywhite junction o o Pathologic diagnosis Boston criteria 65 year old, seizure CTA 15

16 Dural arteriovenous fistula Abnormal vessel near ICH No nidus: direct communication between artery and vein May see tortuous feeders or enlarged venous drainage Usually near skull base Transverse sinus Cavernous sinus Angiography diagnostic Ddx: 61 year old found down CTA 16

17 Ruptured MCA aneurysm Note SAH, IPH, IVH Suspicious location CTA clinches diagnosis Evaluate for active extravasation on delayed images Ddx: 48 yo, headaches Outside CT, 2 days prior 17

Outside MR, 2 days prior Hemorrhagic venous

Frontoparietal (Superior sagittal sinus)

SAH: cortical venous thrombosis Nonhemorrhagic

OCPs Pregnancy/post partum Sinus/mastoid

18 Outside MR, 2 days prior Hemorrhagic venous infarct Unusual or bilateral ICH SAH Frontoparietal (Superior sagittal sinus) Thalamic (Deep venous/vein of Galen) Isolated SAH: cortical venous thrombosis Nonhemorrhagic infarction Vasogenic edema Associated with OCPs Pregnancy/post partum Sinus/mastoid infection Severe dehydration Noncontrast CT Delta Sign CTV Empty Delta 18

Sigmoid sinus thrombosis Dural venous thrombosis CT

hypoplastic sinus Downsides: Radiation, contrast MR

Subacute: hyperintense on T1 and T2 Can be trickier than

19 Sigmoid sinus thrombosis Dural venous thrombosis CT Venogram: Manifests as filling defect Easier to detect hypoplastic sinus Downsides: Radiation, contrast MR Venogram: Manifests as loss of flow related signal Subacute: hyperintense on T1 and T2 Can be trickier than CTV due to artifacts (turbulent flow, slow flow) Safe Ddx: 77 year old, found down 19

20 DWI FLAIR T1 pre T1 post Hemorrhagic metastases Small cell lung cancer Previously undiagnosed 2-3% of ICH Common hemorrhagic mets: Lung Breast Melanoma Renal cell Thyroid cancer Choriocarcinoma GBM can hemorrhage 34 yo, aphasic after partying 20

Drug induced vasculitis (cocaine) Presentation: Intraparenchymal

will look similar to that from other causes ICH may be related to

Vasculitis may be related to direct drug injury or from

21 Drug induced vasculitis (cocaine) Presentation: Intraparenchymal hemorrhage Subarachnoid hemorrhage Ischemic stroke/tia Vasculitis will look similar to that from other causes ICH may be related to BP spikes after cocaine use. Vasculitis may be related to direct drug injury or from contaminants. Drugs include: Amphetamines, cocaine, heroin, ergots Scenario 4: Lobar hemorrhage Differential diagnosis: 21

22 Intraparenchymal hemorrhage, causes by age Under 40 years, 50% have underlying vascular malformation 2/3: AVM 1/3: Cavernous malformation Greater than70 years Amyloid angiopathy HTN years old Up to 70% of ICH due to hypertension Variety of causes possible, and deserves workup From: Kim, Practical approaches to Common Clinical Conditions, ARRS 2010 Causes of IPH Cause Incidence Clues Hypertension 50-60% Known HTN, Basal ggl or posterior fossa Unknown/amyloid 15-25% Lobar hemorrhage, elderly person. Can also be SDH or SAH Coagulopathy 5-25% Fluid fluid level. History/meds AVM 6% <40 yo, IPH with SAH or IVH Aneurysm 3-5% Associated SAH or IVH Cavernous malformation 2-3% Hemorrhage<3 cm, calcification Neoplasm 2-3% Edema Venous thrombosis 2% Lobar, young person, female Drugs (cocaine, meth) 1-2% Young person Vasculitis <1 % Young person From: Kim, Practical approaches to Common Clinical Conditions, ARRS 2010 Imaging algorithm: Nontraumatic IPH on CT Stable, reasonable prognosis? NO: Consider OR or stop evaluation YES: CTA: Vascular lesion? YES: DSA and Rx NO: Known HTN or coagulopathy? YES: Clinical follow up. Consider MR in 6 weeks NO: High risk patient (young, SAH, IVH, lobar in young person)? YES: DSA. If normal: MRI AND/OR Repeat DSA in 1-2 months NO: MRI with GRE and Contrast (IPH protocol) Underlying lesion? YES: Rx as appropriate No: Consider follow up MRI and/or DSA 22

Outline Case-based approach to nontraumatic intracranial hemorrhage 1. Subarachnoid hemorrhage 2.

23 Imaging algorithm There are exceptions to every algorithm Use clinical judgment to tailor algorithm Young person requires a full work up to exclude underlying structural lesion. Outline Case-based approach to nontraumatic intracranial hemorrhage 1. Subarachnoid hemorrhage 2. Intraventricular hemorrhage 3. Lobar intraparenchymal hemorrhage 4. Deep Intraparenchymal hemorrhage Thank you! Kathleen Fink ktozer@uw.edu Cherry blossoms on the UW Quad. Photo by Katherine B. Turner/ UW 23

Diagnosis of Subarachnoid Hemorrhage (SAH) and Non- Aneurysmal Causes

Diagnosis of Subarachnoid Hemorrhage (SAH) and Non- Aneurysmal Causes By Sheila Smith, MD Swedish Medical Center 1 Disclosures I have no disclosures 2 Course Objectives Review significance and differential