Cerebral haemorrhagic contusions are a type of intracerebral haemorrhage and are common in the setting of significant head injury. They are usually characterised on CT as hyperdense foci in the frontal lobes adjacent to the floor of the anterior cranial fossa and in the temporal poles.
Contusions, by definition, result from head trauma and are thus seen more frequently in young males. Typical causes include motor vehicle accidents or situations in which the head strikes the ground.
Most contusions represent the brain coming to a sudden stop against the inner surface of the skull (contrecoup) accentuated by the natural contours of the skull (see below).
- intraventricular haemorrhage in ~2.5% 7
Cerebral contusions can occur anywhere, but have a predilection for certain locations, as a result of the direction of the head strike and the intrinsic shape of the skull cavity.
Typically cortical contusions become more apparent on follow-up imaging due to further bleed or surrounding oedema. Hence on follow-up CT scans in the first couple of days after trauma, one may detect the increase in number and size of the lesions but the patient may not show any clinical deterioration.
Furthermore, the appearance of contusions will vary according to when they are imaged. Typically they mature over some weeks, initially appearing as merely haemorrhagic foci, followed by the development of surrounding oedema, before gradually fading away leaving behind more or less distinct areas of gliosis.
In most hospitals, CT is usually the first and often the only investigation used to assess cerebral contusions. Sensitivity to detect intracerebral haemorrhage on CT scans is virtually 100%.
Hounsfield units (HU) of blood are dependent on protein concentration (i.e. haemoglobin) and haematocrit.
With a haematocrit of 45% the density of whole blood is ~56 HU while the grey matter is 37-41 HU and white matter is 30-34 HU. So blood should be hyperdense in comparison to grey or white matter.
Of note, in anaemic patients (i.e. haemoglobin <8-10 g/dL) blood may appear isodense in an acute bleeding.
Contusions vary in size and can appear as small petechial foci of hyperdensity/haemorrhages involving the grey matter and subcortical white matter or large cortical/subcortical bleed.
Signal behaviour is strongly dependent on sequence and time since the bleeding started.
- diffuse axonal injury
- cerebral contusions undergo expected evolution of blood products whereas cavernoma stay stable or re-bleed
- look for an associated DVA
- 1. Flint AC, Manley GT, Gean AD et-al. Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury. J. Neurotrauma. 2008;25 (5): 503-12. doi:10.1089/neu.2007.0442 - Pubmed citation
- 2. D'avella D, Cacciola F, Angileri FF et-al. Traumatic intracerebellar hemorrhagic contusions and hematomas. J Neurosurg Sci. 2001;45 (1): 29-37. - Pubmed citation
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- 4. Kim J, Smith A, Hemphill JC et-al. Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. AJNR Am J Neuroradiol. 2008;29 (3): 520-5. doi:10.3174/ajnr.A0859 - Pubmed citation
- 5. Parizel PM, Makkat S, Van miert E et-al. Intracranial hemorrhage: principles of CT and MRI interpretation. Eur Radiol. 2001;11 (9): 1770-83. Eur Radiol (link) - Pubmed citation
- 6. Wada R, Aviv RI, Fox AJ et-al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007;38 (4): 1257-62. doi:10.1161/01.STR.0000259633.59404.f3 - Pubmed citation
- 7. Castillo M. Neuroradiology Companion: Methods, Guidelines, and Imaging Fundamentals. LWW. ISBN:1451111754. Read it at Google Books - Find it at Amazon
Stroke and intracranial haemorrhage
stroke and intracranial haemorrhage
- general discussions
- scoring and classification systems
- by region
- hemispheric infarcts
- frontal lobe infarct
- parietal lobe infarct
- temporal lobe infarct
- occipital lobe infarct
- internal capsule infarct
- ataxic hemiparesis syndrome: MCA perforators or basilar artery perforators
- lacunar infarct
- thalamic infarct
- striatocapsular infarct
- cerebellar infarct
- midbrain infarct
- pontine infarct
- Brissaud-Sicard syndrome
- facial colliculus syndrome
- Gasperini syndrome: basilar artery or AICA
- inferior medial pontine syndrome (Foville syndrome): basilar artery
- lateral pontine syndrome (Marie-Foix syndrome): basilar artery or AICA
- locked-in syndrome: basilar artery
- Millard-Gubler syndrome: basilar artery
- Raymond syndrome: basilar artery
- medullary infarct
- acute spinal cord ischaemia syndrome
- hemispheric infarcts
- by vascular territory
- anterior cerebral artery infarct
- anterior choroidal artery infarct
- anterior inferior cerebellar artery infarct
- basilar artery infarct
- middle cerebral artery infarct
- posterior cerebral artery infarct
- posterior inferior cerebellar artery infarct
- superior cerebellar artery infarct
- treatment options
- by region or type
- basal ganglia haemorrhage
- cerebellar haemorrhage
- cerebral contusions
- cerebral microhaemorrhage
- haemorrhagic venous infarct
- haemorrhagic transformation of an ischaemic infarct
- hypertensive intracranial haemorrhage
- intraventricular haemorrhage (IVH)
- lobar haemorrhage
- pontine haemorrhage
- extra-axial haemorrhage
- extradural versus subdural haemorrhage
- extradural haemorrhage (EDH)
- intralaminar dural haemorrhage
- subdural haemorrhage (SDH)
- subarachnoid haemorrhage (SAH)
- intra-axial haemorrhage
- ischaemic stroke