Examine the single slice non-contrast CT image, depicted below, of a 58-year-old male who was brought to the Emergency Department with a headache. He was not on any medication.

a) Name the structures labelled A- E.
 
b) Describe lesion F as you would on the phone to a neurosurgical colleague.
 
c) Give three pathological causes for F.
 
A day after the CT scan the patient's Glasgow Coma Scale drops from 13 to 10.
 
d) Give three possible intracranial causes for this.
 
e) List five validated features affecting prognosis for patients with F.

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College Answer

a)
A Left frontal cortex
B Caudate nucleus
C Top of quadrigeminal cistern (not 3rd or 4th ventricle)
D Septum pellucidum
E Posterior horn of left lateral ventricle

 

b)
'Acceptable' answer:
There is a hyperdensity in keeping with an intracerebral haematoma in the right frontoparietal region with midline shift and surrounding oedema.

 

c)
 Hypertensive haemorrhage.
 AV malformation.
 Haemorrhagic transformation of ischaemic stroke.
 Bleed into tumour.
 (No evidence of subarachnoid haemorrhage).

 

d)
 Expanding haematoma / Worsening oedema / mass effect.
 Seizure (including non-convulsive).
 Hypdrocephalus due to obstruction of ventricles.

 

e)
The features included in the intracerebral haemorrhage score are:
 Age: < 80 or > 80
 GCS: on transfer from the ED to definitive to care.
 Location of bleed: supra vs infra tentorial.
 Volume of Bleed: < 30 mL or > 30 mL.
 Intraventricular extension of haemorrhage.

 

Discussion

The image above is not the gospel CICM image, but was stolen shamelessly from a 2009 article by Jae-Suk Park et al.

The answers to a), b), c) and d) should be a part of an ICU trainee's reptilian hindbrain activity.

If one's cross-sectional neuroanatomy was for some reason sub-optimal, one could pay a visit to the excellent wikiradiography Head CT page.

Differential explanations for "a hyperdensity in keeping with an intracerebral haematoma" are:

  • Intracerebral haematoma, due to
    • Hypertension
      • Potentially associated with abuse of stimulants, eg.cocaine
    • Amyloid angiopathy
    • Arteriovenous malformation
    • Intracranial aneurysm (though there is no subarachnoid blood)
    • Cavernous angioma
    • Venous angioma
    • Dural venous sinus thrombosis
    • Haemorrhage into the intracranial neoplasm
    • Haemorrhage into an ischaemic stroke (haemorrhagic transformation)
    • Vasculitis

This list of differentials was retrieved from an excellent 2001 NEJM article by Adnan Qureshi.

The college then asks for five validated features which affect prognosis. Fortunately, an article titled"Development and validation of the Essen intracerebral haemorrhage score" can rescue us from wondering what hidden meaning the College had concealed within the remark I italicised. Presumably, the examiner behind it is also aware of, and perhaps is mildly annoyed by, several published prognostic features for ICH which are completely unvalidated.

The specific scoring system referred to in the official model answer was probably the modified Essen ICH score rather than the original ICH score. One can view the original system here and Essen scoring system here. Detailed familiarity with them is not essential; however one should recall that the following variables suggest a poor prognosis:

 

References

References

Park, Jae-Suk, et al. "Remote cerebellar hemorrhage complicated after supratentorial surgery: retrospective study with review of articles." Journal of Korean Neurosurgical Society 46.2 (2009): 136-143.

Qureshi, Adnan I., et al. "Spontaneous intracerebral hemorrhage." New England Journal of Medicine 344.19 (2001): 1450-1460.

Hemphill, J. Claude, et al. "The ICH score a simple, reliable grading scale for intracerebral hemorrhage." Stroke 32.4 (2001): 891-897.

Weimar, Christian, Jens Benemann, and H. C. Diener. "Development and validation of the Essen intracerebral haemorrhage score." Journal of Neurology, Neurosurgery & Psychiatry 77.5 (2006): 601-605.

Rost, Natalia S., et al. "Prediction of Functional Outcome in Patients With Primary Intracerebral Hemorrhage The FUNC Score." Stroke 39.8 (2008): 2304-2309.

Garrett, John S., et al. "Validation of Clinical Prediction Scores in Patients with Primary Intracerebral Hemorrhage." Neurocritical care 19.3 (2013): 329-335.