Imaging of Spontaneous Brain Hemorrhage: the basics!

[@JulianYedlin]

It is always a pleasure to watch your classes, the explanations, the images and the way you do it is spectacular. Thank you so much! We look forward to more and more!

[@theneuroradiologist]

Thanks for this really nice comment!

[@inmyhead_sharon421]

Thank you for making this video. I admin a cpl of CAA facebook groups and will share your video there.

[@sim_aware]

Another great discussion! Thank you!

[@theneuroradiologist]

Thanks, you're welcome :)

[@farizaevloeva-n8k]

Amazing as always! Thank you so muc!

[@HalaNourYounes]

amazing lecture thank you

[@ma222ma2]

thank you 👍👍👍👍

[@abelsahle5298]

Great lectures as always, I have 2 questions the first is can we differentiate or is there a sign that help us to differentiate between lobar hemorrhage caused by CAA and dural venous sinus thrombosis on CT scan? and the second is if we do not have the previous CT scan, can we differentiate between hemorrhagic transformation from spontaneous intracerebral hemorrhage? Thank you.

[@theneuroradiologist]

Hello there. Good questions. Concering CAA vs. CVST: There are no 100% discriminating characteristics in my experience. If I see a lobar hemorrhage in an elderly patient I'll suggest CAA as this is the most likely cause and I'll advise an MRI to confirm the diagnosis. If this patient were to have a CVST I'd expect this to be visible on MRI (even without dedicated venous imaging, as thrombus in the dural sinuses will cause signal changes). In a younger patient with a lobar hemorrhage I'll advise doing CT-angiography in the acute setting because CAA is less likely and we want to rule out vascular causes. On most CT-angiographies you also have opacification of the dural sinuses beause it's technically difficult to get a pure CT-angiography. This often allows evaluation of dural sinuses as well. CVST hemorrhages often occur in so-called "venous territories" --> for instance if you have bilateral parafalxiene hemorrhages, check for a thrombus in the superior sagittal sinus, for a temporal lobar hemorrhage, evaluate the transverse sinus and Labbé vein. When you see a lot of edema surrounding smaller patchy hemorrhages, CVST is also more likely, because you'll first get venous edema and only hemorrhage in a second time (when venules start to rupture due to the increased venous pressure). So there are some situations where you can prefer one above the other, but in the end for ultimate confirmation you'll need MRI and/or vascular imaging. Concerning hemorrhagic transformation versus spontaneous ICB: can also be difficult is the hemorrhage is large. If the hemorrhage is limited and surrounded by edema respecting vascular territories hemorrhagic transformation of an acute ischemic infarction is most likely. Keep in mind that most spontaneous ICB's (due to hypertension or CAA) do not invoke a lot of edema, so if you see a lot of edeam surroundnig a hemorrhage, that's when you have to think about alternative diagnoses liek tumoral hemorrhage, CVST or hemorhagic transformation. Hope this is helpful.

[@venkatraamudu]

Thank you so much Dr Dekeyzer for the wonderful teaching ❤ Is there any standard anatomical level to measure midline shift? Because it is quite confusing as one reports 7mm and another as 4 mm because two of them measures at different (somehow anterior /posterior) levels to septum pellucidum or is it just at the maximum deviation of septum pellucidum from the midline?

[@theneuroradiologist]

there are several methods, the one I use is explained in the video on traumatic brain injury and on how to read a brain CT, but needless to say if two radiologists measure something (whatever it is) you will have some measuring error or inter-observer measurement variability.

[@AAhmed-sf7zp]

Thank you a lot for these lectures! You look a lot like Ricky Pointing :d