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July2007 Vol.44 Issue:      2 Table of Contents
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Spontaneous Intracerebral Hematoma in Young People: Clinical and Radiological Magnetic Resonance Imaging Features by Diffusion-Weighted Images

Saleh Attia1, Mohamed G. El Khatib1, Maha Bilal2, Hoda Nassar1

Departments of Neurology1, Radiology2, Mansoura University



ABSTRACT

Background: Spontaneous intracerebral hematoma (ICH) accounts for 10% to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage. The etiologic spectrum of ICH in young people may be wider than in older individuals and includes vascular malformation, hypertension, and drug use. Objectives: The aim of this work is to study risk factors, causes, sites, and early prognosis of spontaneous intracerebral hematoma (ICH) in young people through determining the clinical and radiographic features of the cases selected at different stages using Diffusion-Weighted images (DW-I) in comparison with different conventional Magnetic resonance imaging (MRI) sequences. Patients and Methods: This study was carried out on 40 (16 males and 24 females) young patients (15-45 years old) with spontaneous ICH who were admitted to the neurology department in Mansura Emergency Hospital or Mansura University Hospital. They underwent thorough history taking, neurological examination, laboratory investigation and radiological imaging in the form of non-contrast axial Computed tomography (CT) scan of the brain in 38 patients, conventional MRI with multiple sequences including T1-, T2-, FLAIR-, GRE-WIs and D-WI & apparent diffusion coeffient (ADC) map in all patients. MR angiography and digital subtraction angiography were done in 27 and 9 patients respectively. According to the time interval between symptoms onset and MRI study, five stages were categorized, hyperacute (n=2), acute (n=5), early subacute (n=12), late subacute (n=14) and chronic (n=7). The signal intensity at different stages of ICH on D-WI and the ADC value were compared with those on the different conventional MRI sequences. Results: The frequency of risk factors among the studied groups showed that hypertension was the commonest risk factor (20 patients). The most common presenting feature of ICH young patients is focal neurological deficits 92.5%. The commonest cause was hypertension 42.5% followed by AVM 20%. Among the 40 patients 12 patients died within the first month with a mortality rate 30%. All hematomas were proved on CT and appeared as hyperdense lesions. Different MR signal intensities were identified on the D-WI and conventional MRI sequences. D-WI and ADC values identified different stages of ICH. Conclusion: ICH in young people needs more research studies. Hypertension is the most common risk factor for stroke in young adults. AVM, aneurysm, and cavernous angioma must be considered as possible cause in each case of ICH in young people even in presence of hypertension. The addition of D-WI and ADC map to conventional MRI study helps the differentiation of various stages of ICH from acute infarction as well as the characterization of intracranial hemorrhagic lesion.

(Egypt J. Neurol. Psychiat. Neurosurg., 2007, 44(2): 561-576)

 




INTRODUCTION

 

Spontaneous ICH is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10% to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage (SAH)1.

The incidence of ICH in people aged <35 years has been estimated to be 0.3/100000 2,3. The frequency of ICH among a series of stroke in young adults varies from 0.7% to 40%  4,5.                                             

The etiologic spectrum of ICH in young people may be wider than in older individuals and includes vascular malformations, hypertension, and drug use6-8.

The classic presentation of spontaneous ICH is sudden onset of focal neurological deficit progressing over hours   with   headache,   nausea, vomiting, altered consciousness, and elevated blood pressure9.

The management of ICH remains an enigma. Despite its relatively high incidence and poor associated outcomes neither medical nor surgical intervention has been shown consistently to improve outcome.  Limited success in establishing efficacious therapies is due, in part, to the limited quantity and quality of clinical studies10.

Although CT remains the diagnostic test of choice in the setting of acute ICH because of its exquisite sensitivity and specificity for small amounts of ICH. MRI is an excellent tool for the diagnosis and evaluation of ICH with its unique specificity to hemoglobin degradation   products  in  different  stages11.

Despite the frequent use of conventional MRI to evaluate the appearance and underlying biophysical basis of evolving ICH  over the past few years, D-WI has only recently been recognized as a valuable investigation resource12,13.

Diffusion-WI is a relatively new technique which, by using additional strong diffusion-sensitizing gradients, is extremely sensitive to change in the microscopic motion of water protons. It has proved valuable in the study of natural history of ischemic stroke, the early detection of cerebral infarction and detection of hyperacute and acute hemorrhage14.

 

Aim of the work:

The aim of this work is to study the risk factors, causes, sites and early prognosis of spontaneous ICH in young people through determining the clinical and radiographic features of the cases selected at different stages using D-WI in comparison with conventional MR imaging sequences.

MATERIALS AND METHODS

  

Prospective study included forty  young  patients (16 males and 24 females) of spontaneous ICH who were admitted to neurology departments in Mansoura University Emergency hospital and Mansoura University Hospital.

The Inclusion criteria were age of the patients not more than 45 years at the time of ICH, and evidence of diagnosis of Spontaneous intra cerebral hematoma.

The Exclusion criteria were primary subarachniod hemorrhage, traumatic intracerebral hemorrhage, and previous diagnosis of vascular malformation, aneurysm, and brain tumor (as the cause of ICH was already diagnosed).

Diagnosis of cases was based on clinical neurological examination and confirmed by computed tomography of the brain.

Patients were subjected to thorough history taking and neurological examination, complete laboratory investigation, CT head scan in all cases (except two pregnant patients in first trimester), conventional Magnetic Resonance imaging of the brain and D-WI in all patients and Magnetic Resonance angiography of the brain in 27 cases, all MRI studies were done on 1.5-T unit (Magnetom Symphony, Siemenes, Version VA12A). Digital subtraction angiography was done in 9 cases only because of refusal, critcal clinical conditions or difficulty to access.

MR studies were done at various intervals after the onset of symptoms and the five ICH stages were defined according to the examination, hyperacute (0-12 hours, n=2), acute (13 hours-3 days, n=5), early subacute (4-7 days, n=12), late subacute (8-30 days, n=14) and chronic (31days or more, n=7).

                The conventional MRI study was done in the axial, sagittal and coronal planes using the following sequences; T1-WI (TR/TE=500-600/14-15 msec.), T2-WI (TR/TE=2500-4490/82-90 msec.), FLAIR-WI (TR/TE/TI= 9000/14/2500 msec.) and GRE-WI (TR/TE/FA= 425x15x20). The slice thickness was 5 mm, the matrix was 256 x 256 and field of view (FOV) was 230 mm. Diffusion-W MR images was obtained using a multislice single shot spin  area of interst were done. Technical factors were TR=2200 msec, TE=139 msec, NEX=8-16, bandwidth=125 KHz FOV=25-30 cm, slice thickness=5 mm. the diffusion gradients were applied in three orthogonal direction (X, Y& Z). Diffusion trace MR images were acquired with a D-W factor b of o & 1000 sec/mm and apparent diffusion coefficient (ADC) map was reconstructed and was compared with contralateral normal side.

To calculate the ADC values a region of interest (ROI) was located on the ADC map at the center of each ICH as seen at D-WI, as well as in the contralateral normal white matter. Each ROI was 5-20 mm according to the size of the hematoma.

The statistical of data was done by using Excel Program and SPSS Program [Statistical Package of Social Science version 10] on windows 98. First part of data was descriptive in form of mean +/- SD and frequency and proportion. Second part was analytic to test statistical significant difference between groups. For qualitative data [frequency and proportion] chi-square test was used.

For quantitative data [mean +/- SD] student t-test was used to compare difference between groups. One way Anova was used to compare more than 2 groups. *P is significant if ≤ 0.05 at confidence interval 95%.

 

RESULTS

 

This study was carried out on 40 young patients (15-45 years old) with spontaneous ICH. The frequency of risk factors among the studied groups showed that hypertension was the commonest risk factor (20 patients). There is significant statistical relation between hypertension as a risk factor and age group as p=0.001. Smoking comes next (10 patients) as shown in table (1).

The most common presenting feature of ICH young patients as shown in table(2) is focal neurological deficits 92.5% followed by headache 67.5% and then disturbed conscious level in 62.5%.

Causes of ICH in the studied group are shown in the table (3). The commonest was hypertension 42.5% followed by AVM 20%.

Table (4) shows the sites of ICH in our study, while table (5) shows the relations between the clinical presentations, causes and sites of ICH in our study. Among 40 patients, 12 died in the first month with a mortality rate of 30%.

All ICH were proved by CT except in two pregnant ladies. Table (6) shows the signal intensities of ICH according to the various stages demonstrated on MR images.

Table 1. Frequency of risk factor in relation to age.

 

Risk factor

Age 15-25

Age 16-35

Age 36-45

Total

P

Hypertension

-

2

18

20(50%)

0.001

Tobacco use

-

2

8

10(25%)

0.077

Bleeding diathesis

-

-

3

3(7%)

0.418

Diabetes mellitus

-

-

4

4(10%)

0.302

 

Table 2.  The commonest clinical presentations of ICH.

 

Presentation

No. of patients

Percentage

Focal motor and or sensory deficit

37

92.5%

Headache

27

67.5%

Disturbed conscious level

25

62.5%

Manifestation of ↑ ICT

14

35%

Fits

7

17.5%

Speech disorders

5

12.5%

Table 3. Causes of ICH.

 

Cause

No .of patients

Percentage

Hypertension

17

42.5%

AVM

8

20%

Undetermined

5

12.5%

Bleeding tendency

3

7.5%

Aneurysm

2

5%

Pregnancy related complications

2

5%

Cavernous angioma

2

5%

Vasculitis

1

2.5%

Total

40

100%

 

Table 4. The sites of ICH.

 

Site

No. of patients

Percentage

Lobar

26

65%

Intraventricular extension

19

47.5%

Ganglionic

6

15%

Multiple

6

15%

Brain stem

1

2.5%

Cerebellum

1

2.5%

 

Table 5. The relation between presentations, sites and causes of ICH.

 

Cause

Site

Headache

Disturbed  conscious level

Focal motor and or sensory deficit

Manifestation of increased ICT

Speech disorders

Fits

Hypertension

Lobar

7

6

10

1

2

-

Ganglionic

1

1

4

1

-

-

Cerebellar

1

1

1

-

-

-

Multiple

2

1

2

1

2

-

AVM

Lobar

4

4

5

2

1

1

Ganglionic

-

-

1

-

-

-

Multiple

1

2

2

1

-

-

Cavernous angioma

Lobar

1

1

1

-

-

1

Brain stem

1

-

1

-

-

-

Aneurysm

Lobar

1

-

1

1

-

-

Multiple

1

-

-

1

-

-

Bleeding tendency

Lobar

-

1

1

1

-

-

Multiple

1

1

1

1

-

-

Pregnancy related complications

Lobar

1

2

2

1

-

2

Vasculitis

Lobar

1

-

1

-

-

-

Undetermined

Lobar

2

2

4

3

-

3

Ganglionic

2

2

1

-

-

-

Table 6. Determination of the ICH Score*.

 

ICH Score points

Component

GCS Score

ICH volumes, cm3

IVH

3-4

2

5-12

1

13-15

0

Infratentorial origin of ICH

30

1

<30

0

GCS Score

ICH volumes, cm3

Yes

1

No

0

IVH

Infratentorial origin of ICH

Yes

1

No

0

Age, Y

80

1

<80

0

Total ICH Score

0.6

* Hemahill J. Bonovich D. Besmertis L. et al. 15

 

 

Table 7. Relation between cause and ICH scoring.

 

Cause

ICH  Score

0-2

ICH Score

3-6

Total

Hypertension

14

3

17

AVM

6

2

8

Cavernous angioma

2

0

2

Aneurysm

2

0

2

Bleeding tendency

1

2

3

Pregnancy related complications

1

1

2

Vasculitis

1

0

1

Undetermined

3

2

5

 

 

 

Table 8. The relation between the cause and 1st 30 days mortality.

 

Cause

No. of patients

No. of deaths

Percentage

Pregnancy related complications

2

2

100%

Bleeding tendency

3

2

66.7%

Undetermined

5

2

40%

Hypertension

17

5

29.4%

AVM

8

1

12.5%

Aneurysm

2

0

0%

Vasculitis

1

0

0%

Cavernous angioma

2

0

0%

Table 9. MRI signal intensities of ICH according to various stages with different pulse sequences.

 

Stage

No.

of patients

T1-WI

T2-WI

Flair-WI

GRE-WI

D-WI

ADC value

Hyperacute

2

Isointense

Hyperintense

Hyperintense

Mixed intensity

Hyperintense

decreased

Acute

5

Isointense

Hypointense

Hypointense

Hypointense

Hypo + hyperintense rim

decreased

Early subacute

12

Hyperintense

Hypointense

Hypointense

Hypointense

Hypo + hyperintense rim

decreased

Late subacute

14

Hyperintense

Hyperintense

Hyperintense

Hyper or isointense

(2)

Hyperintense

decreased

Chronic

7

Hypointense

Hyper + hypointense rim

Isointense (5)

Mixed (2)

Hyper + hypointense rim

Isointense(5)

Mixed(2)

elevated

 


Illustrated cases

 

Case (1):  45 year-old male patient presented with acute right hemiparesis, fits and late subacute left tempro-parietal hematoma due to AVM, obtained 18 days after the onset of symptoms.

 (A)    Non contrast axial CT scan of the brain: shows large hyperdense area of fresh blood density is seen in the left tempro-parietal region, surrounded by mild degree of perifocal oedema and exerts mass effect in the form of effacement of the ipsilateral left lateral ventricle and effacement of the adjacent cortical sulci.

(B)           T1-W axial image, (C) T2-W axial image and (D) FLAIR-WI: show letempro-parietal hyperintense lesion.

(E)           GRE-W image: shows isointense left tempro-parietal lesion with hypointense area surrounding.

(F)           D-WI at b1000: shows the hyperintense lesion.

(G)          ADC map: shows the hypointense signal with decreased ADC value.

(H)          MRA: shows the hyperintense resolving hematoma, with tortuous vessels at its lateral aspect.

(I)     Digital subtraction angiography: shows the underlying AVM with its feeding   arteries, nidus and draining veins.

Case (2): 20 year-old female patient presented with headache and manifestation of increase ICT with late sub acute to early chronic frontal hematoma and intraventricular extension due to anterior cerebral artery aneurysm obtained 32 days after the onset of symptoms.

 

(A)    Non contrast axial CT scan of the brain: shows right frontal heterogeneously hyperdense area with mild perifocal oedema and associated with intraventricular extension in the forth ventricle.

(B)    T1-W axial image: shows hypointense core (chronic) with a hyperintense surrounding rim (late subacute) and exerts mass effect in the form of contralateral shift of midline structures.

(C)    T2-W axial image, (D) FLAIR-WI, (E) GRE-WI and (F) D-WI b1000: show right frontal heterogeneous hyperintense lesion with hypointense rim on T2-, GRE-, D-WIs. There is similar blood density is seen in the right frontal horn of lateral ventricle impressive of right frontal late subacute hematoma with intraventricular extension.

(G)          ADC map: shows the hypointense signal with decreased ADC value.

(H)          MRA: shows the resolving hyperintense hematoma obscuring the adjacent   vessels.

(I)            Digital subtraction angiography: shows right anterior cerebral artery aneurysm (arrow).


Case (3): 42 year-old hypertensive male patient presented with right hemiparesis showing acute and  early subacute left fronto-tempro-patietal and thalamic hematoma obtained 4 days after the onset of symptoms.

 

(A)    Non contrast axial CT scan of the brain: shows hyperdense area of blood collection is seen in the left fronto-tempro-parietal and left thalamic region surrounded by moderate degree of hypodense perifocal oedema, it exerts mass effect in the form of compression the left lateral ventricle and contralateral shift of midline structures.

(B)    T1-W axial image: shows the mixed (iso-(acute) and hyperintense hematoma (early subacute)) signal intensity hematoma in the left fronto-tempro-parietal and left thalamic region, associated with moderate perifocal oedema and exerting mass effect in the form of compression of the related lateral ventricle and shift of midline structures.

(C)    T2-W axial image, (D) FLAIR-WI and (E) GRE-WI: depict the hypointense hematoma.

(F)    D-WI b1000: depicts the hematoma as markedly hypointense and surrounded by a continuous rim of bright signal intensity.

(G)    ADC map: shows the hypointense signal with decreased ADC value.

(H)    MRA: reveals the resolving hematoma displacing the adjacent anterior cerebral artery.


Case (4):  43 year-old hypertensive male patient presented with right hemiparesis and late subacute left deep tempro-parietal hematoma obtained 20 days after the onset of symptoms.

  

(A)    Non contrast axial CT scan of the brain: shows left deep tempro-parietal hyperdense area of fresh blood density surrounded by moderate hypodense perifocal oedema and exerting mass effect in the form of effacement of ipsilateral lateral ventricle.

(B)    T1-W axial image, (C) T2-W axial image, (D) FLAIR-WI, (E) GRE-WI and

(F)    D-WI b1000: depict left deep tempro-parietal hyperintense lesion with moderate less hyperintense perifocal oedema and mass effect by compressing the contralateral lateral ventricle.

(G)    ADC map: shows the hypointense signal with decreased ADC value.

(H)    MRA: shows the resolving hyperintense hematoma.


Case (5): 42 year-old male patient presented with fits and headache showing early subacute left frontal hematoma due to cavernous angioma obtained four days after the onset of symptoms.

 

(A)    Non contrast axial CT scan of the brain: shows small hyperdense area of fresh blood density is seen in the left frontal region with no surrounding oedema or mass effect.

(B)    T1-W axial image: shows a well defined small area of high signal intensity is seen in the left frontal region surrounded by hypointense rim with no related oedema or significant mass effect.

(C)    T2-W axial image, (D) GRE-WI and (E) D-WI b1000:  depict a markedly hypointense lesion representing the cavernous angioma and surrounding hematoma.

(F)           ADC map: shows the hypointense signal with decreased ADC value.

(G)          MRA:  shows normal study.

 


Case (6): 17-year-old female patient presented with right hemiparesis showing  hyperacute large left fronto-parietal hematoma due to ruptured AVM, obtained 4 hours after the onset of symptoms.

 

 

* CT Brain was not done as the patient was pregnant in the first trimester.

(A)    T1-W sagittal image: shows large left fronto-parietal isointense area with hypointense rim of moderate perifocal oedema associated with cortical multiple areas of signal void intensity representing AVM.

(B)    T2-W coronal image and (C) FLAIR-W axial image: show the hematoma is hyperintense, and a thin hypointense rim is seen inside the region of perilesional edema.

(D)          GRE-W sagittal image: shows the lesion is of mixed signal intensity.

(E)           Digital subtraction angiography: shows the underlying AVM.

 

 


DISCUSSION

 

Spontaneous ICH accounts for 10–30% of strokes, with greater relative frequencies in Chinese and Japanese series. Stroke affects 3.7–5% of those aged 15-4516. The usual pattern of MR appearances corresponding to the different stages of ICH is well known. The generalized model for the appearance of ICH on MR images attributes the various signal intensity (SI) patterns of evolving ICH to the oxygenation state of hemoglobin and the integrity of the red blood cells14.

In the current study we examined 40 patients that were diagnosed to have ICH by the clinical neurological examination and confirmed by CT of the brain except in two pregnant ladies. Conventional and D-W magnetic resonance imaging were done to all patients at various intervals after the onset of symptoms and five stages were defined, hyperacute stage in two patients, acute in 5, early subacute in 12, late subacute in 14 and chronic stage in 7 patients. The D-W signal intensity and ADC values were compared to the conventional MRI sequences.

Hypertension is the single most important modifiable risk factor for ICH. Regardless of race, age, or gender, it seems that approximately 75% of ICH patients have preexisting hypertension. Hypertension is the dominant risk factor for ICH among men and women aged 18 to 49 years17,18. In the current series, hypertension presented 50% of the risk factors, followed by smoking in 25%, bleeding diathesis and diabetes mellitus in 10% for each. This was similar to what recorded in other studies19-21.

                In this work; focal neurological deficits (92.5%) were the most common symptoms in our study. An early decrease in level of consciousness is seen in 50% of patients with ICH by study of Caplan9, although in our’s 62.5% of patients presented with disturbed conscious level. Twenty seven of the patients (67.5%) in our study presented with headache. Compared with study of Joseph, et al, 22, headache occurs in 40% of patients with ICH, Seizures are more common in hemorrhagic stroke than in ischemic stroke. They occur in up to 28% of hemorrhagic strokes and generally occur at the onset of the ICH or within the first 24 hours23.  Seven patients (17.5%) in the present study presented with seizures.

As regard the cause of ICH, hypertension represented the commonest cause of ICH in the present series (42.5%), however, and compared with other causes, this produced the worst outcome and resulted in high morbidity, mortality. Compared with the results of hypertension-inducing hemorrhage from Mexico: 11% 24, the USA: 15.3%, 15.2%5,6, Taiwan: 37.6%25. The percentage of hypertension-inducing hemorrhage in a study of stroke in young blacks26 was 64.2%.

In this series, the second cause of ICH was rupture of vascular malformations, including both AVM (20%) and cavernous angioma (5%). Ganglion hemorrhage was mainly caused by hypertension while lobar hemorrhage was caused by vascular anomalies in our study. In Lin et al.26, study most cases of ICH were lobar and putaminal. Of the lobar hemorrhages, 26.5% resulted from ruptured AVM. Of the putaminal hemorrhages, they found 60% resulted from arterial hypertension26. In a study of intracranial hemorrhage David et al.27, it is said that individuals younger than 45 years, lobar hemorrhage is the most common site of and frequently is associated with AVMs. Also in our study, lobar hemorrhage was the commonest.

Approximately 20% of all large ICH are caused by ruptured aneurysms. Although some degree of intraparenchymal bleeding is often seen during aneurysmal hemorrhage28. We diagnosed two of our patients (5%) to have ruptured aneurysm with good outcome and no mortality.

The ICH Score is an accurate predictor of outcome assessed as 30-day mortality. Each increase in the ICH Score was associated with a progressive increase in 30-day mortality. This was evident in the entire cohort of ICH patients29.  In our study most of deaths had ICH score more than 2.

ICH appears at once on CT as a well-demarcated high-density round or oval area, with or without rupture into the ventricles or on to the surface of the brain30. In the present study, CT scan helped in detection of site, size and shape of hematomas as well as the ventricular extension. All that helped us to identify the cause of hemorrhage, and to predict the 30-days mortality by detecting the ICH score for each patient.

In many clinical situations, D-WI has become an integral part of MRI examination as it is the imaging modality of choice for the assessment of the tissue viability that helps the early management of patients with acute cerebral ischemia. On the other hand an accurate discrimination between ischemic and non-ischemic stroke, especially the acute ICH, is needed before the initiation of thrombolytic or other interventional treatment to get the optimal treatment outcome31,32.

Kang et al., 14 described the hyperacute hematoma to be isointense on T1-WI, hyperintense on T2-W, FLAIR-W and D-W images and mixed SI on GRE-WI, with hypointense rim in all sequences and decreased ADC value. This was almost similar to what was reported in our study, although the hypointense rim attributed the intracerebral deoxyhemoglobin at the periphery of hematoma which was reported to occur within the first few hours of hemorrhage was not detected. This hypointense rim although may not be obvious on conventional T1- and T2-WIs, it is more apparent on conventional GRE-WI and most prominent on echo planner GRE-WI, its importance is due to its ability in differentiating acute ischemic stroke from hemorrhage in patients with acute neurological symptoms14.

The precise biophysical explanation for decreased ADC value at the core of the hyperacute hematoma may be due to shrinkage of extracellular space due to resorption of plasma with clot retraction which causes high viscosity 33 or due to changes in the conformation of hemoglobin molecule and a contraction of intact red blood cells together with decreased intracellular space34.

We were in accordance with Kang et al.14, who described the acute and early subacute ICH (case 2,3) to be hypointense on T2-, FLAIR-, GRE- and D-WIs which shows a surrounding hyperintense rim on the latter sequences. Although the acute ICH is isointense on T1-WI and the early subacute ICH is hyperintense on the same pulse sequences, both stages shows decreased ADC values in the center of the hematoma with relative increased value in the peripheral hyperintense rim compared with the normal contralateral white matter. This hypointense signal has been attributed to the magnetic field inhomogenicity caused by the paramagnetic intracellular deoxyhemoglobin in acute hematoma and paramagnetic intracellular methemoglobin in early subacute hematoma35,36.

Wiesmann et al.37, suggested the suscetability artifact as a possible cause of the hyperintense rim shown by D-WI to surround the acute and subacute hematomas. In our study the rim was not apparent on the GRE-WI which showed a stronger susceptibility effect than D-WI. We were in accordance with Kang et al.14, who believed that this hyperintense rim is not caused by a suscebitibilty artifact due to a paramagnetic intracellular deoxyhemoglobin or methemoglobin, but may be related to the T2 shine through effect caused by vasogenic edema surrounding the hematoma, which is evidenced to correspond to the hyperintense perilesional edema seen on T2-WI and that is why its ADC value is higher than that of the normal contralateral white matter.

In this series, the late subacute ICH showed hyperintense signal on all pulse sequences and decreased ADC value except two hematomas showed isointense signal on the GRE-WI. Apart from these two hematomas we were in agreement with Kang et al.14. We believed that the variations in the ADC value do not depend simply on whether or not the red blood cell membranes are intact as in the late subacute stage there is red blood cell lysis and the compartmentalization of methemoglobin is lost resulting in elimination of the inhomogeneous susceptibility effect, as well as the raised viscosity by the extracellular distribution of the intracellular  contents, in addition to other biological changes such as high cellularity resulting from the proliferation of inflammatory cells and macrophages. This was similar to what reported in several studies12,14,35,36.

                We were similar to many studies36,38,39, who found the characteristic paramagnetic hemosidrin and ferritin at the periphery of chronic ICH is seen as a dark rim surrounding the hematoma on T2- and D-WIs. In the current series, the SI of chronic hematoma was isointense (n=5) and mixed hypo- and isointense (n=2) on D-WI with elevated ADC value in all chronic ICH. This goes with what recorded by Kang et al.14, who reported an isointense signal at the early chronic stage and hypointense at the late chronic stage as well as elevated ADC values in chronic hematomas.

Cerebral angiography remains the gold standard for visualizing cerebrovascular anatomy40. In Toffol et al.'s study6, angiography was diagnostic in 49.2% of patients with further study. In our study conventional angiography was diagnostic in the 9 cases which were done for them. Although MRA was helpful in diagnosis of vascular lesions, its value was limited by the hyperintense signal of the subacute hematoma obscuring the underlying pathology.

 

 

Conclusion:

ICH is a common cause of stroke in young adults and in this in group hypertension is the most common risk factor. Special programs must be done to avoid its complications. The addition of D-WI and ADC map to conventional MRI study with its multiple sequences is helpful for the differentiation of ICH with its various stages from acute infarction and for the further characterization of intracranial hemorrhagic lesion.

 

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الملخـص العربـى

 

تمثل حالات النزف المخى التلقائي من عشره الي خمسه عشره فى المائه من حالات السكته الدماغيه. كما تعتبر معدلات الوفيات الناتجه عن النزف المخى التلقائي اعلى من معدلات الوفيات الناتجه عن الجلطات الدماغيه او النزيف تحت الام العنكبوتيه.

وتعتبر حالات السكتات الدماغيه فى صغار السن شائعه. وتقدر حالات النزف المخى التلقائى فى صغار السن بحوالى من واحد الى اربعون فى المائه من حالات السكتات الدماغيه فى صغار السن. ويعد ارتفاع ضغط الدم، التدخين، مرض البول السكرى، امراض النزف من اهم عوامل الخطورة. وايضا تعتبر التشوهات الشريانيه الوريديه، مع ارتفاع ضغط الدم من اهم الاسباب فى هذه الفتره العمريه.

تهدف هذه الدراسه الى بيان اهم عوامل الخطوره، واسباب، والاعراض الاكلينكيه لحالات النزف المخى التلقائى فى صغار السن عن طريق دراسه الاعراض الاكلينكيه والخصائص الشعاعيه.

اشتملت هذه الدراسه على اربعين مريض فى المرحله العمريه من خمسه عشر الى خمس واربعين عاما ويعانون من النزف المخى التلقائى. وقد خضعوا الى فحص طبى اكلينيكى شامل، اشعه مقطعيه على المخ، اشعه الرنين المغناطيسى على المخ، وحقن الشريان السباتى لبعض هذه الحالات (تسعه حالات) وقد تبين ان نصف هذه الحالات يعانون من ارتفاع ضغط الدم كاهم عوامل الخطوره، يليه التدخين فى ربع الحالات ثم مرض البول السكرى.

كما تبين ان ارتفاع ضغط الدم من اهم الاسباب، يليه التشوهات الشريانيه الوريديه. وقد تنوعت الاسباب الاخري ما بين التمدد الوعائى بالمخ، امراض النزف، تسمم الحمل والفتره التى بعده. وقد توفى اثنى عشره حاله فى اول شهر بعد الاصابه معظهم ناتج عن ارتفاع ضغط الدم.



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