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Endgames Case Review

An expanding intracerebral haematoma

BMJ 2015; 351 doi: (Published 25 September 2015) Cite this as: BMJ 2015;351:h5014
  1. Peter Birkeland, senior clinical fellow12,
  2. Lisbeth Høgedal, staff radiologist3,
  3. Frantz Poulsen, senior consultant24
  1. 1King’s College Hospital, Department of Neurosurgery, London SE5 9RS, UK
  2. 2Department of Neurosurgery, Odense University Hospital, Odense, Denmark
  3. 3Department of Radiology, Odense University Hospital
  4. 4Institute of Clinical Research, University of Southern Denmark, Odense
  1. Correspondence to: P Birkeland

A 44 year old man presented to the emergency department with a sudden onset headache. He had no medical history of note and took no drugs. Urgent computed tomography of the head was performed (fig 1). A repeat scan (eight minutes later) was performed after administration of intravenous contrast (OptiRay) (fig 2). Upon return from the radiology department, he developed left sided hemiplegia. His blood pressure was 179/90 mm Hg. After another 46 minutes, computed tomography (fig 3) with angiography (not shown) was performed; no abnormal vessels were seen. Blood tests did not show an underlying coagulopathy. He subsequently deteriorated to localising to pain and making incomprehensible sounds to pain without opening his eyes (Glasgow coma score 8). His pupils remained equal and reactive to light.

Fig 1 The patient’s initial computed tomogram of the head

Fig 2 Repeat computed tomogram (eight minutes later) after administration of intravenous contrast

Fig 3 Repeat computed tomogram (54 minutes after the first)

The sequence of scans (figs 1-3) depicts an expanding intracerebral haematoma.


  • 1. What causes of this bleed should be considered?

  • 2. How should blood pressure be managed in patients with acute intracerebral haemorrhage?

  • 3. When should surgical evacuation be considered?

  • 4. What other management options could be considered?

  • 5. How common is haematoma expansion?


1. What causes of this bleed should be considered?

Short answer

Aneurysmal subarachnoid haemorrhage should first be suspected in patients with a history of sudden onset headache. However, in this case the initial scan shows a small haematoma in the right basal ganglia rather than a subarachnoid haemorrhage. In patients with haemorrhage in the basal ganglia hypertension is the most common cause. Other causes include ruptured arteriovenous malformation, cavernoma, and tumour related haemorrhage.


Aneurysmal subarachnoid haemorrhage should be at the top of the list of differential diagnoses in patients with a …

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