Causes of spontaneous intracerebral haemorrhage, investigations and characteristics
| Causes | Investigations | Characteristics |
|---|---|---|
| Hypertensive arteriopathy | MRI including T2 GRE or SWI sequence | Presence of deep-seated cerebral microbleeds, leukoaraiosis and lacunar infarctions is supportive. |
| Cerebral amyloid angiopathy | MRI including T2 GRE or SWI sequence Apolipoprotein E (ε2 and ε4 alleles) | MRI: lobar haemorrhage, microhaemorrhages at cortico-subcortical junctions. Carrier of Apolipoprotein ε2 and ε4 alleles have higher risk of recurrent sICH. |
| Cavernoma | MRI | MRI: heterogeneous signal intensities on T1 and T2 with a hypointense surrounding rim. Typically described as ‘popcorn’ or ‘berry’ appearance. |
| Arteriovenous malformation | MRI, MRA, DSA | MRA/DSA: dilated arteries feeding a nidus and multiple draining veins. |
| Intracranial aneurysm | CTA, MRI, MRA, DSA | Presence of subarachnoid haemorrhage. DSA is the gold standard in detecting aneurysm. |
| Cerebral venous thrombosis | CTV, MRV | Clinical signs of increased intracranial pressure. Symmetrical haemorrhagic infarctions. Filling defect (flow void) in the venous system. |
| Dural arteriovenous fistula | CTA, MRA, DSA | Haematoma location near venous sinus and cortical veins. |
| Brain tumour/metastasis | CECT/MRI | 50% of patients with brain metastasis will have multiple lesions that may show contrast enhancement. |
| Anticoagulant | History/coagulation profile | Prolongation of coagulation profile. In patients on NOACs, the presence of normal coagulation profile does not indicate absence of coagulopathy. |
| Thrombolysis agent | History | Diagnosis of prior ischaemic stroke or myocardial infarction requiring thrombolysis is usually evident. |
| Cocaine and sympathomimetic drugs | History | Elevated urine cocaine levels can be detected within 72 hours of cocaine use. |
| Urine cocaine levels |
CECT = contrast-enhanced computerised tomography; CTA = computerised tomography angiography; CTV = computerised tomography venography; DSA = digital subtraction angiography; GRE = gradient recall echo; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging; MRV = magnetic resonance venography; NOAC = novel oral anticoagulants; SWI = susceptibility-weighted imaging