Utility of early MRI in the diagnosis and management of acute spontaneous intracerebral hemorrhage

Abstract

Background: The optimal diagnostic evaluation for spontaneous intracerebral hemorrhage (ICH) remains controversial. In this retrospective study, we assessed the utility of early magnetic resonance imaging (MRI) in ICH diagnosis and management.

Methods: Eighty-nine (72%) of 123 patients with spontaneous ICH underwent a brain CT and MRI within 30 days of ICH onset. Seventy patients with a mean age of 62 ± 15 years were included. A stroke neurologist and a general neurologist, each blinded to the final diagnosis, independently reviewed the admission data and the initial head CT and then assigned a presumed ICH cause under 1 of 9 categories. ICH cause was potentially modified after subsequent MRI review. The final 'gold standard' ICH etiology was determined after review of the complete medical record by an independent investigator. Change in diagnostic category and confidence and the potential impact on patient management were systematically recorded.

Results: Mean time to MRI was 3 ± 5 days. Final ICH diagnosis was hypertension or cerebral amyloid angiopathy (CAA) in 50% of patients. After MRI review the stroke neurologist changed diagnostic category in 14%, diagnostic confidence in an additional 23% and management in 20%, and the general neurologist did so in 19, 21 and 21% of patients, respectively. MRI yield was highest in ICH secondary to ischemic stroke, CAA, vascular malformations and neoplasms, and did not differ by age, history of hypertension, hematoma location or the presence of intraventricular hemorrhage.

Conclusions: The results of this study suggest potential additive clinical benefit of early MRI in patients with spontaneous ICH.

Fig. 1

Brain imaging studies in a 69-year-old hypertensive female with a spontaneous left frontoparietal lobar ICH. The CT diagnosis of ICH from a ‘tumor’ or ‘unknown etiology’ (a) was changed to ICH from CAA after the MRI review due to the presence of peripheral microbleeds on gradient echo MRI (b) and lack of enhancement on the T₁-weighted postcontrast MRI (c).

Fig. 2

Brain imaging studies in a 60-year-old hypertensive male with a spontaneous left thalamic ICH. The CT diagnosis of hypertensive ICH (a) was changed after MRI review to ICH caused by a cavernous angioma (b, c). MRI shows a well-circumscribed lesion with a heterogenous reticulated core on the T₂-weighted sequence (b) and an associated developmental venous anomaly with a ‘caput medusae’ appearance on the T₁-weighted postcontrast sequence (c). This diagnosis was confirmed surgically.