Hemorrhage 02 - Clinical Case Summary
CA0000-Hemorrhage 02 - Clinical Case Summary
CA0000-Hemorrhage 02 - Clinical Case Summary
SummaryHistory
87 yo female with history of atrial fibrillation and chronic hypertension that presented with an acute seizure.
Exams Performed
Non contrast head CT; T1-w MR precontrast; T1-w MR post contrast; T2-w spin echo; MR T2 flair; MR (SWI) susceptibility
Prior sequence impressions
CT head: noncontrast
1. There is evidence of two recent CNS hemorrhages: a 3 cm acute hematoma in the dorsal right thalamus and a small (< 1 cm) bleed in the left cerebellar dentate nucleus. A small left posterior mid convexity, parietal hyperdensity is evident, but whether it represent a third acute hemorrhage or focal dystrophic calcification is indeterminate. Post constrast head CT reveals no other cause for hemorrhage.
2. There is a small volume of blood in the occipital horns bilaterally.
3. There is prominent, age-related cortical atophic changes.
Non contrast head T1-w MR
1. The right dorsal thalamic hematoma has heterogeneous intensities. Most of it is isointense with only a small central part being hyperintense (met-Hgb); the margin around the hematoma is similar to CSF intensity. There is subtle hyperintense area in the left cerebellar dentate nucleus, again with an adjacent low T1 MR intensity. Findings suggest the acute hemorrhages are recurrent in prior areas of hemorrhage. The left posterior parietal small hemorrhage is isointense to brain.
2. There is local mass effect related to the thalamic right hematoma. There is compression of the right venticular trigone without isolation of the right temporal horn. There is no significant downward incisural herniation.
3. The blood in the occipital horns is present but is less well seen on noncontrast T1 MR sequence.
Post contrast T1 MR
1. The post contrast T1-w MR demonstrates no underlying aneurysm, AVM, or hypervascular mass. There is no arterial or venous thrombosis. The venocapillary thalamic intensity is reduced in the right thalamus compared to the left, but this is consistent with compressive effects of the hematoma and the thalamic edema. The contrast volume is not absent to suggest an ischemic stroke.
MR flair
1. MR flair again demonstrates the above hemorrhage sites, but also demonstrates a lack of transependymal fluid migration precluding active hydrocephalus.
MR susceptibility (SWI)
1. SWI demonstrates both the sites of recent hemorrhage into the right dorsal thalamus and the left dentate cerebellar nucleus, as well as the characteristic features of chronic hypertensive encephalopathy with multicentric sites of chronic microhemorrhages.
1. There is evidence of two recent CNS hemorrhages: a 3 cm acute hematoma in the dorsal right thalamus and a small (< 1 cm) bleed in the left cerebellar dentate nucleus. A small left posterior mid convexity, parietal hyperdensity is evident, but whether it represent a third acute hemorrhage or focal dystrophic calcification is indeterminate. Post constrast head CT reveals no other cause for hemorrhage.
2. There is a small volume of blood in the occipital horns bilaterally.
3. There is prominent, age-related cortical atophic changes.
Non contrast head T1-w MR
1. The right dorsal thalamic hematoma has heterogeneous intensities. Most of it is isointense with only a small central part being hyperintense (met-Hgb); the margin around the hematoma is similar to CSF intensity. There is subtle hyperintense area in the left cerebellar dentate nucleus, again with an adjacent low T1 MR intensity. Findings suggest the acute hemorrhages are recurrent in prior areas of hemorrhage. The left posterior parietal small hemorrhage is isointense to brain.
2. There is local mass effect related to the thalamic right hematoma. There is compression of the right venticular trigone without isolation of the right temporal horn. There is no significant downward incisural herniation.
3. The blood in the occipital horns is present but is less well seen on noncontrast T1 MR sequence.
Post contrast T1 MR
1. The post contrast T1-w MR demonstrates no underlying aneurysm, AVM, or hypervascular mass. There is no arterial or venous thrombosis. The venocapillary thalamic intensity is reduced in the right thalamus compared to the left, but this is consistent with compressive effects of the hematoma and the thalamic edema. The contrast volume is not absent to suggest an ischemic stroke.
MR flair
1. MR flair again demonstrates the above hemorrhage sites, but also demonstrates a lack of transependymal fluid migration precluding active hydrocephalus.
MR susceptibility (SWI)
1. SWI demonstrates both the sites of recent hemorrhage into the right dorsal thalamus and the left dentate cerebellar nucleus, as well as the characteristic features of chronic hypertensive encephalopathy with multicentric sites of chronic microhemorrhages.
Overall impression
1. Two recent hemorrhages into the right dorsal thalamus and the left cerebellar dentate nucleus. There is a small dystrophic calcification in the left parietal cortex of no acute significance.
2. There are characteristic microhemorrhages in the cerebrum and pons indictating a background of chronic hypertensive encephalopathy, No other lesion is evident as a cause for CNS hemorrhage.
2. There are characteristic microhemorrhages in the cerebrum and pons indictating a background of chronic hypertensive encephalopathy, No other lesion is evident as a cause for CNS hemorrhage.
Lessons to be Learned
1. Chronic hypertensive encephalopathy typically reveals multicentric hemosiderin laden punctate chronic microhemorrhages located in characteristic locations: centronuclear structures, mid pons, cerebellar dentate nuclei and often gray-white matter junctions.
2. Acute exacerbation of hypertension results in hemorrhages in the same sites, often multiple. There can also be recent and subacute hemorrhages evident concurrently.
2. Acute exacerbation of hypertension results in hemorrhages in the same sites, often multiple. There can also be recent and subacute hemorrhages evident concurrently.
