Emergency Radiology Course – Brain, Bleed

This emergency CT brain lecture by Andrew is all about brain bleeds. He begins with intra-axial hemorrhages
and then covers extra-axial hemorrhages.

5 Review Questions

Question 1:
Which of the following locations is NOT typical of a hypertensive hemorrhage?
basal ganglia
cerebellar hemispheres
pons
subcortical white matter
thalamus

Question 2:
What is the most common cause of lobar hemorrhages in the elderly?
arteriovenous malformation
cerebral amyloid angiopathy
ischemic infarction with transformation
poorly controlled hypertension
underlying primary tumor

Question 3:
A 30-year-old man presents to the emergency
department with a history of head injury. CT brain
below demonstrates right-sided extradural hematoma.
What important sign is shown in the image that
represents active bleeding within the hematoma?

cord sign
fogging sign
hyperdense vessel sign
spot sign
swirl sign
Question 4:
Skull bone sutures typically hinder the extension of...
extradural (epidural) hematomas
subarachnoid hematomas
subdural hematomas
subgaleal hematomas

Question 5:
A trauma patient with a head injury and reduced GCS has a hemorrhage within the corpus callosum. What is the
likely mechanism for the bleed?
contra-coup
coup
infarction
shearing
subfalcine herniation

Explanation

Question 1:
Hypertensive intracerebral hemorrhages most commonly occur (in order of frequency) in the:
 basal ganglia (most common)
 thalamus
 pons
 cerebellum
Peripheral "lobar" hemorrhages are characteristic of cerebral amyloid angiopathy.

Question 3:
Swirl sign refers to the non-contrast CT appearance of acute extravasation of blood into a hematoma. It represents
unclotted fresh blood that is of lower attenuation than the clotted blood that surrounds it.

Question 4:
The morphology of extradural hematomas is best understood by reviewing their relationship to the bone and dura.
An extradural hematoma is actually a subperiosteal hematoma located on the inside of the skull, between inner
table of the skull and parietal layer of the dura mater (which is the periosteum). As a result, EDHs are usually
limited in their extent by the cranial sutures, as the periosteum crosses through the suture continuous with the
outer periosteal layer. This is, therefore, helpful in distinguishing EDHs from subdural hematomas, which are not
limited by sutures.

Question 5:
Hemorrhage within the corpus callosum is indicative of a shearing-like mechanism. Shearing forces — such
as rotational acceleration; most often a deceleration — can result in diffuse axonal injuries. Patients with diffuse
axonal injuries will typically have a loss of consciousness at the time of the accident. Involvement of the corpus
callosum would come under a grade II diffuse axonal injury.
Related Articles
Intra-axial hemorrhage
 intracerebral hemorrhage
 hypertensive hemorrhage
o basal ganglia hemorrhage
o cerebellar hemorrhage
o pontine hemorrhage
 lobar hemorrhage
o cerebral amyloid angiopathy (CAA)
o hemorrhagic transformation of ischemic infarct
 cerebral hemorrhagic contusion
 diffuse axonal injury
Extra-axial hemorrhage
 extradural hemorrhage (EDH)
 subdural hemorrhage (SDH)
o subdural hygroma
 subarachnoid hemorrhage (SAH)
o traumatic subarachnoid hemorrhage
o ruptured berry aneurysm
 pseudosubarachnoid hemorrhage