Intended for healthcare professionals

Practice Rational Testing

Investigating intracerebral haemorrhage

BMJ 2015; 350 doi: (Published 20 May 2015) Cite this as: BMJ 2015;350:h2484
  1. Duncan Wilson, clinical research fellow1,
  2. Matthew E Adams, consultant neuroradioloist2,
  3. Fergus Robertson, consultant neuroradiologist2,
  4. Mary Murphy, consultant neurosurgeon3,
  5. David J Werring, reader in clinical neurology1
  1. 1Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
  2. 2Lysholm Department of Neuroradiology (R.J.), National Hospital for Neurology and Neurosurgery, London
  3. 3Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London
  1. Correspondence to: D J Werring d.werring{at}
  • Accepted 20 March 2015

The bottom line

  • Non-traumatic (spontaneous) intracerebral haemorrhage is most often “primary” (that is, due to cerebral small vessel diseases, mainly hypertensive arteriopathy or cerebral amyloid angiopathy), but may be secondary to underlying structural lesions or intracranial vascular malformations; there are no reliable indicators of “primary” intracerebral haemorrhage, and further investigation is usually warranted

  • For most patients with non-traumatic intracerebral haemorrhage, non-invasive computed tomography (CT) or magnetic resonance angiography should be a first line test to detect underlying intracranial vascular malformations

  • Consider structural magnetic resonance imaging (MRI) when plain CT and non-invasive angiography fail to reveal a cause for intracerebral haemorrhage; MRI can reveal changes of cerebral small vessel disease, tumours, and haemorrhagic infarcts, preventing unnecessary invasive investigations

  • Do not routinely undertake intra-arterial digital subtraction angiography as it has a procedural risk; it has a role where there remains a high suspicion of an underlying vascular abnormality and non-invasive methods are not diagnostic

A 49 year old, right handed woman presented with sudden left upper and lower limb weakness. Examination confirmed left hemiparesis with Medical Research Council (MRC) grade 3/5 power in the upper limb and 0/5 power in the lower limb. She had been diagnosed with relapsing-remitting multiple sclerosis but had been stable (without relapses) for over a year. Computed tomography (CT) on admission revealed a right frontal intracerebral haemorrhage (fig 1A).

Fig 1 A: Non-contrast computed tomography (CT) head scan revealing acute intracerebral haemorrhage within the right frontal lobe (white arrow) with surrounding oedema (white arrowhead). B: T2 weighted magnetic resonance imaging (MRI) of brain of a patient with intracerebral haemorrhage taken two days after admission confirms a lesion in the left side of the midbrain in the region of the left crus cerebri (white arrow); it shows a peripheral T2 hypointense rim with heterogeneous internal signal, typical of a …

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