Case 21 - Hypertensive Bleed, IPH with IVH: CT

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

CTA head with and without contrast, CTA neck with contrast 4/15/2018

HISTORY: 55-year-old female with history of intracranial hemorrhage

COMPARISON: Outside institution CT head 4/15/2018

TECHNIQUE: Axial noncontrast CT images of the head were obtained followed by axial contrast enhanced CT and radiographic images of the head and neck with 2-D coronal and sagittal reformatted reviewed.

FINDINGS:

Unenhanced CT head:

No significant change in the 2.0 x 0.5 x 0.6 cm (AP by transverse by craniocaudal) hyperdense intraparenchymal hematoma involving the superomedial left thalamus with mild adjacent vasogenic edema.

There is redemonstration of intraventricular extension with a large clot in the left lateral ventricle, and a moderate-sized clot in the right lateral ventricle. Blood products are redemonstrated in the third ventricle, cerebral aqueduct, and the fourth ventricle. The size and distortion of the blood products is similar aside from minimal increase in the layering blood products in the occipital horns of the lateral ventricles.

Stable mild to moderate supratentorial and infratentorial ventriculomegaly, slightly more asymmetrically prominent size of the left lateral ventricle, unchanged. Stable mild periventricular white matter hypoattenuation.

The gray-white matter differentiation is maintained. There is no extra-axial fluid collection. There is no evidence of new intracranial hemorrhage. There is no significant mass effect or midline shift. The basal cisterns are patent.

The orbital contents are normal. The paranasal sinuses and mastoid air cells are clear.

CTA head and neck:

A common origin of the innominate and left common carotid artery is noted, which is a common anatomic variant. The common carotid arteries are unremarkable. The carotid bifurcations are normal. The cervical and intracranial segments of the internal carotid arteries are unremarkable aside from minimal arteriosclerotic calcifications in bilateral cavernous and supraclinoid segments bilaterally with only mild luminal narrowing in the left cavernous ICA. The intracranial carotid bifurcations are normal. The middle cerebral arteries and the bifurcation/trifurcation areas are normal. The anterior communicating arteries and the anterior communicating branch are normal.

The origins of the vertebral arteries are normal. A slightly left dominant vertebral artery system is noted. The cervical and intracranial segments of the vertebral arteries are normal. The origins of the posterior inferior cerebellar arteries are normal. The basilar artery is patent and normal in caliber. The origins of the superior cerebellar and posterior cerebral arteries are normal. The posterior cerebral arteries are patent and normal in caliber.

There are no major branch vessel occlusions, dissections, aneurysms, or flow-limiting stenoses. There is no evidence of vascular malformations.

The visualized soft tissues of the neck are normal aside from scattered mildly prominent bilateral cervical chain lymph nodes, likely reactive. An endotracheal and orogastric tube is partially visualized.

The included portions of the upper lungs are clear.

No suspicious osseous lesions. Multilevel degenerative changes are noted in the cervical spine with no evidence of high-grade spinal canal stenosis.

IMPRESSION:

1. No significant change in the left thalamic hematoma likely representing hypertensive etiology with subsequent extension into the ventricles. Stable mild adjacent vasogenic edema.

2. Redemonstration of intraventricular extension involving all of the supratentorial and infratentorial ventricles, which is unchanged aside from minimal increase in the trace layering blood products in the occipital horns, likely representing redistribution.

3. Stable mild to moderate supratentorial and infratentorial ventriculomegaly likely representing obstructive hydrocephalus with stable suggestion of transependymal flow CSF.

4. Patent head and neck arterial vasculature with no evidence of aneurysm or vascular malformation or source of intraventricular hemorrhage.
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Indication: Intraventricular hemorrhage. Past history of hypertension, diabetes, found at home by her husband face down.

Technique: Outside CT images of the brain and cervical spine from xxx Hospital dated April 15, 2018 were submitted for second opinion interpretation.

Findings:

These images demonstrate casting of the left lateral ventricle with hemorrhage greater than the right lateral ventricle. The left lateral ventricle is somewhat dilated. The third ventricle also has hemorrhage within it and there is hemorrhage in the cerebral aqueduct and within the fourth ventricle. There is the possibility of a small parenchymal hemorrhage seen best on series 2 image 14 at the junction between the thalamus and the third ventricle. Very minimal subarachnoid hemorrhage is identified.

There is moderate ventriculomegaly.

The visualized portions of the calvarium are unremarkable.

Incomplete evaluation of the cervical spine is provided without thin section imaging. The alignment of the vertebral revises anatomic. There is disc space narrowing at C3-4, C4-5, and C5-6. There is mild uncovertebral joint degenerative change also present most notably at C3-4 C4-5 and C5-6. No neck masses are seen. No fractures are seen.

IMPRESSION:

Left greater than right lateral ventricular hemorrhage, third ventricular hemorrhage, cerebral aqueduct hemorrhage, and fourth ventricular hemorrhage. The source is unclear but may be a left thalamic hypertensive bleed.

Degenerative changes in the cervical spine without an acute fracture. The study is limited without thin section imaging.