Nontraumatic Acute Intraparenchymal Hemorrhage: Algorithm for Workup and Differential Diagnosis

Abstract

Nontraumaticspontaneousintracerebralhemorrhage(ICH) accounts for 8%-15% of all strokes 1 and has a poor prognosis, with a mortality rate of almost 50% within the first month and 80% rate of dependency at 6 months from onset. 2 The high rate of early neurologic deterioration after ICH is thought to be related to active bleeding that may occur for hours after symptom onset. Prompt neuroimaging is therefore critical, and it has been shown that patients with symptomatic ICH that undergo earlier neuroimaging are more likely to demonstrate hematoma expansion on subsequent imaging. 3,4 Identification of patients who are more likely to have hematoma expansion is an active area of research, and there are many ongoing therapeutic trials targeting this specifi cp atient population at risk, including Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II), The Spot Sign for Predicting and Treating ICH Growth Study (STOP-IT), and “Spot Sign” Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy (SPOTLIGHT). In this article, we review the different imaging modalities and provide an algorithm (Fig. 1) for the workup of patients presenting with nontraumatic intraparenchymal hemorrhage (IPH). A differential diagnosis of etiologies and imaging manifestations of primary vs secondary IPH has also been presented.