Recognizing intracranial hemorrhage

Step-by-step approach

1. 1

   Density and time

   Hyperacute-to-acute blood is bright; over 1–2 weeks it becomes isodense to brain, then hypodense. A subacute isodense subdural is a classic trap.

2. 2

   Extradural

   Lentiform (lens-shaped), limited by sutures, usually arterial and post-traumatic — often with an overlying fracture.

3. 3

   Subdural

   Crescentic, crosses sutures but not dural reflections; common in older patients and may follow trivial trauma.

4. 4

   Subarachnoid

   Blood in sulci and cisterns. Non-traumatic SAH means aneurysm until proven otherwise.

5. 5

   Intraparenchymal and intraventricular

   Location suggests cause: basal ganglia favours hypertension; lobar in older patients suggests amyloid; always note intraventricular extension.

6. 6

   The four modifiers

   Every hemorrhage report needs: location, size, intraventricular extension, and midline shift/mass effect.