Differentials
Cerebral aneurysm
SIGNS / SYMPTOMS
Aneurysmal haemorrhage typically presents with sudden-onset severe headache.
INVESTIGATIONS
CT head distinguishes subarachnoid blood from intracerebral haemorrhage. However, both cerebral aneurysms and arteriovenous malformation (AVMs) may cause subarachnoid or intracerebral haemorrhage.
MRI and/or angiogram distinguish the underlying pathology.
Cavernous haemangioma
SIGNS / SYMPTOMS
Most frequently present with seizures. Haemorrhages tend to be small and their effects depend on their location. They are rarely the source of significant intracerebral haemorrhages, although a brainstem location, focal deficits, and previous haemorrhage are all risk factors.
INVESTIGATIONS
MRI distinguishes cavernous hemangioma from AVM unless haematoma obliterates the underlying lesion.
The 'popcorn' MRI appearance of cavernous malformations is pathognomonic.
Dural arteriovenous fistula
SIGNS / SYMPTOMS
Frequently cause pulsatile tinnitus, and a bruit can often be heard over the fistula. Arteriovenous fistulas tend to present with symptoms of raised intracranial pressure secondary to increased cerebral venous pressure such as headaches and visual impairment. Haemorrhage is less common.
INVESTIGATIONS
Direct visualisation of the fistula on MRI and angiogram.
Hypertensive intracerebral haemorrhage
SIGNS / SYMPTOMS
Known history of hypertension.
INVESTIGATIONS
Cerebral angiography excludes AVM.
Developmental venous anomaly
SIGNS / SYMPTOMS
No differentiating signs/symptoms. Mostly asymptomatic with low risk of bleeding.
INVESTIGATIONS
MRI and cerebral angiography can differentiate this from an AVM. Caput medusae appearance in venous phase.
Intracerebral haemorrhage from drug misuse
SIGNS / SYMPTOMS
History of drug use (cocaine, amphetamines, ecstasy) immediately before onset of symptoms.
INVESTIGATIONS
May or may not be associated with an underlying AVM.
Cerebral angiography is recommended to exclude an underlying lesion.
Intracerebral haemorrhage from anticoagulation
SIGNS / SYMPTOMS
History of anticoagulant therapy. Excessive cutaneous bruising and ecchymoses may suggest over-anticoagulation. Vascular lesions cannot be completely excluded simply because of history of anticoagulant therapy.
INVESTIGATIONS
Coagulation profile should be sought.
Cerebral angiography may be required to exclude an underlying AVM (e.g., patients who are over-anticoagulated may still bleed from an unrecognised AVM).
Amyloid angiopathy
SIGNS / SYMPTOMS
Older patients. History of cognitive decline or seizures.
INVESTIGATIONS
No specific tests are available to diagnose amyloid angiopathy, which is usually a diagnosis of exclusion. On CT imaging, lobar haemorrhages with superficial location and cortical involvement, with or without local extension to the subarachnoid and intraventricular spaces, suggest cerebral amyloid angiopathy-related haemorrhage.
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