Intracranial hemorrhage

• Severe headache (as a worst headache of the life)
• Headache is the main symptom (often starts suddenly and starts after a popping or snapping feeling in the head)
• Double vision
• Nausea and vomiting
• Symptoms of meningeal irritation
• Sudden decreased level of consciousness
• Rapid progression of symptoms

• The modality of choice for diagnosis of subarachnoid hemorrhage is noncontrast head computed tomography (CT), with or without lumbar puncture.^[1]
• CT shows hyperattenuating material filling the subarachnoid space.

• Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show:
  • Elevated opening pressure
  • Elevated red blood cell (RBC)
  • Xanthochromia

• Headache
• Neck stiffness
• Fever

• Photophobia (inability to tolerate bright light)
• Phonophobia (inability to tolerate loud noises)
• Irritability, altered mental status (in small children)

• CT scan of the head may be performed before LP to determine the risk of herniation.

• Diagnosis is based on clinical presentation in combination with CSF analysis.
• CSF analysis is the investigation of choice.
• For more information on CSF analysis in meningitis please click here.

• Headache
• Nausea
• Vomiting
• Change in mental status
• Seizures
• Focal symptoms of brain damage
• Associated comorbid conditions like tuberculosis, etc

• CT or MRI is the initial test to detect intracranial lesions.
• These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.

• Biopsy of the lesion is needed to identify the nature of the lesion such as:
  • Tumor
  • Abscess

• X- ray of the skull is a non specific test, but useful if any of the lesions are calcified.

• Headache, vomiting, and depressed level of consciousness from increased intracranial pressure (ICP)

• Progression of focal neurological deficits over periods of hours

• CT scan without contrast is the initial test performed to differentiate ischemic stroke and rule out hemorrhagic stroke.
• CT is very sensitive for identifying acute hemorrhage which appears as hyperattenuating clot.
• Gradient echo and T2 susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.

• PT/ INR and aPTT should be checked to rule out coagulopathy.

• CT scan without contrast is the initial test performed to diagnose ischemic stroke and rule out hemorrhagic stroke. CT may show hypo-attenuation and swelling of involved area.
• MR diffusion weighted imaging is the most sensitive and specific test for diagnosing ischemic stroke and may help detect presence of infarction in few minutes of onset of symptoms.

• Carotid doppler may be done to check for patency of carotid arteries and blood supply to the brain.

• Cerebral angiography is an invasive test and detect abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations).

• Headache: It is a common presentation (present in 90% of cases); it tends to worsen over a period of several days, but may also develop suddenly (thunderclap headache).^[1] The headache may be the only symptom of cerebral venous sinus thrombosis.^[2]
• Inability to move one or more limbs.
• Weakness on one side of the face.
• Seizures: 40% of all patients have seizure.
• Depressed level of consciousness and otherwise unexplained changes in mental status are common symptoms in the elderly.^[4]

• The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus.

• CT and MRI may identify Cerebral edema and venous infarction may be apparent.

• CT venography detects the thrombus, computed tomography with radiocontrast in the venous phase (CT venography or CTV) has a detection rate that in some regards exceeds that of MRI.

• Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the “corkscrew appearance”.

• Severe or moderate headache (which is often one-sided and pulsating) lasts between several hours to three days.
• Other symptoms include gastrointestinal upsets, such as nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (phonophobia). Approximately one third of people who experience migraine get a preceding aura.^[4]

• CT and MRI may be needed to rule out other suspected possible causes of headache.

• Headache
• Confusion
• Drowsiness
• Personality change
• Seizures
• Nausea and vomiting
• Loss of consciousness
• lucid interval

• CT scan is the first test performed and identifies cerebral hemorrhage (appears as hyperattenuating clot) following head injury. CT scan is also less time consuming.

• MRI is more sensitive, takes more time and is done in patients with symptoms unexplained by CT scan.

• The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury.
• The Pediatric Glasgow Coma Scale is used in young children.

• Mass lesion effect such as headache or visual field defects
• Hypopituitarism

• CT & MRI typically reveal features of a pituitary mass.

• The most accurate test is pituitary biopsy which will show lymphocytic infiltration.

• Headache
• Impairment of mental function is the most prominent feature such as personality change, impairment of memory, confusion, learning difficulties
• Focal neurological abnormalities and evidence of raised intracranial pressure

CT & MRI will show:

• Focal radiation necrosis
• Diffuse white matter injury
• Contrast-enhancing mass surrounded by edema and mass effect

• Radiation necrosis is hypo metabolic and will have decreased uptake of fluorodeoxyglucose.