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Alen Emmanuel Joshy: CT Brain in Intracranial Hemorrhage
Alen Emmanuel Joshy/LinkedIn
Dec 20, 2025, 23:44

Alen Emmanuel Joshy: CT Brain in Intracranial Hemorrhage

Alen Emmanuel Joshy, MRI Technician at AKG Memorial Cooperative Hospital, shared on LinkedIn:

”CT Brain in Intracranial Hemorrhage

Technical and Protocol Points:

  • Non-contrast CT (NCCT) is mandatory initially — contrast can obscure acute blood.
  • Thin slices (≤5 mm, preferably 1–2 mm) improve detection of small bleeds.
  • Bone window helps identify associated skull fractures.
  • Repeat CT is crucial in deteriorating patients to assess bleed progression.

Density and Physics Insight:

  • Acute blood appears hyperdense (60–80 HU) due to high protein and iron content.
  • Density reduces over time due to clot lysis and dilution by CSF.
  • Hematocrit level influences bleed conspicuity on CT.

Evolution of Hemorrhage on CT:

  • Hyperacute (<6 hrs): May appear heterogeneous due to active bleeding (“swirl sign”)
  • Acute (6 hrs–3 days): Homogeneously hyperdense
  • Early chronic: Peripheral membrane formation may be seen

Signs Suggesting Active or Severe Bleed:

  • Swirl sign: Hypodense area within hyperdense clot → ongoing bleeding
  • Spot sign (on CTA): Predictor of hematoma expansion
  • Mass effect disproportionate to bleed size

Important Secondary Effects:

  • Raised intracranial pressure (ICP)
  • Herniation (subfalcine, transtentorial, tonsillar)
  • Acute obstructive hydrocephalus (especially with IVH or SAH)

Etiology Clues Based on Location:

  • Basal ganglia bleed: Hypertension
  • Lobar hemorrhage: Amyloid angiopathy, tumor, anticoagulation
  • Cerebellar bleed: Life-threatening due to brainstem compression
  • Temporal lobe bleed: Consider trauma or aneurysmal SAH extension

When to Add CT Angiography?

  • Suspected aneurysm or AVM
  • Young patient with no hypertension
  • Lobar hemorrhage without trauma
  • SAH with negative NCCT after 6 hours

Pitfalls and Mimics on CT:

  • Calcifications vs acute bleed
  • Beam-hardening artifacts
  • Contrast staining post-procedure
  • Dense venous sinuses mimicking SAH

Clinical Correlation Matters:

  • Sudden severe headache → rule out SAH
  • Trauma with lucid interval → EDH
  • Elderly with minor trauma → SDH
  • Anticoagulated patients → high risk of expansion

Take-Home Message:

  • CT brain not only detects hemorrhage but also predicts severity, guides management, and helps identify the cause. Early recognition saves lives.”

Hemorrhage

Stay informed with Hemostasis Today.

Alen Emmanuel Joshy Anticoagulation bleeding Cerebellar Bleed CT Brain Health Hematology hemorrhage Hemostasis Today Intracranial Hemorrhage Medicine
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