Brain trauma/bleeding/vascular

Diffuse axonal Injury

Grade 1: grey white matter junction

Grade 2: corpus callosum

Grade 3: brainstem

CT blood age

hyperacute- <1hr

• hypodense

acute - 1hr to 3 days

• hyperdense

subacute - 4 days to 3 weeks

• progressively less dense

chronic - >3 weeks

• hypodense

Swirl sign

• hyperacute blood mixed in with acute blood

• ACTIVE BLEEDING

MR blood age

Hyperacute - <24 hrs

• Iso/Bright

Acute - 1-3 days

• Iso/Dark

Early Subacute - 3-7 days

• Bright/Dark

Late Subacute - 7-14 days

• Bright/Bright

Chronic - >14 days

Dark/Dark peripherally, central bright

cortical superficial siderosis

etiology

• subarachnoid haemorrhage

• cerebral amyloid angiopathy

CF:

• mostly asymptomatic

• sensorineural hearing loss

• ataxia

low signal on SWI/GRE

Benign Non-aneurysm Perimesencephalic hemorrhage

anterior to brainstem

venous bleed most likely

needs NEGATIVE CT ANGIOGRAM

Hypertensive haemorrhage

basal ganglia(putamen)

thalamus

pons

cerebellum

look for intraventricular extension

Cerebral amyloid angiopathy

associations

• alzheimer

• down syndrome

ImF

• lobar haemorrhage

  • occipital/temporal

• cerebellar hemorrhage

• microhaemorrhage

  • subcortical

• convexity subarachnoid haemorrhage

• cortical superficial siderosis

• microinfarcts

convexity subarachnoid haemorrhage

etiologies

• cerebral amyloid angiopathy

• trauma

• posterior reversible encephalopathy syndrome PRES

• reversible cerebral vasoconstriction syndrome RCVS

• dural venous sinus thrombosis

• AV malformation

• Dural AV fistula

Lobar haemorrhage differentials

Spontaneous

• hypertensive

• CAA

Secondary

• AVM

• Cavernoma

• tumour

• venous thrombosis

• vasculitis

bilateral thalamic stroke

etiology

• artery of percheron thrombosis

• basilar tip thromboembolic occlusion

• bilateral internal cerebral vein thrombosis

recurrent artery of heubner stroke

caudate nuclear infarct

Factors that increases risk of cerebral AVM haemorrhage

• small AVM

• small draining vein

• associated aneurysm

• basal ganglia location

Dural AV Fistula

acquired

sigmoid sinus involvement →tinnitus

can be OCCULT on MRI/MRA

→ catheter angiogram 

developmental venous anomaly (DVA)

congenital

association

• blue rubber bleb naevus syndrome

• cavernous malformation

Caput Medusa Sign

• many veins converge into a single draining vein

cavernous malformation

low flow

congenital

acquired via radiotherapy

supratentorial

peripheral rim of T2 dark(haemosiderin)

fluid-fluid level- recent haemorrhage

associated with DVA

capillary telangiectasia

low flow

congenital

acquired via radiotherapy

favors PONS

T1 isointense

T2 slightly hyperintense

‘brush like’ ‘stippled pattern’ of enhancement

Blooming on SWI

BEST SEEN ON SWI

calcified habenular

curvilinear calcified structure

posterior margin of 3rd ventricle

association

• schizophrenia

Moyamoya Disease

Bimodal: 4-5, 40-50

progressive non-atherosclerotic stenosis

supraclinoid ICA

enlargement of basal perforating arteries

• puff of smoke - DSA

Complication

• adult - bleed

• child - stroke

Association

• Child - sickle cell

• NF

• prior radiation

• Downs syndrome

Crossed cerebellar diaschisis

corticopontine-cerebellar pathway

Supratentorial insult causing contralateral cerebellar hypometabolism on FDG-PET

top of basilar syndrome

visual and oculomotor deficits

behavioural abnormalities

somnolence, hallucinations and dreamlike behaviour

acute basilar artery occlusion

sudden death/LOC

top of basilar syndrome

locked in syndrome

proximal - thromboembolic/atherosclerosis with thrombosis

middle - atherosclerosis with thrombosis

distal(top) - thromboembolic