Early imaging in spontaneous intracranial hemorrhage: Practices and etiological diagnosis

PurposeSpontaneous intracerebral hemorrhage (ICH) has a poor prognosis. Early imaging <72 hours is essential for etiological and prognosis assessment. We aimed to describe early imaging practices and evaluate their etiological relevance, before adopting standardized protocols.MethodsAcute spontaneous ICH patients from two university centers (2021-2022) were retrospectively included. Data included imaging, lesion, and associated vascular lesions parameters. Etiologies were classified into six categories based on imaging and clinical criteria: arteriolosclerosis, cerebral amyloid angiopathy (CAA), mixed cerebral small vessel disease (cSVD: arteriolosclerosis + CAA), vascular malformation, tumor, or undetermined.ResultsAmong 450 patients (71 ± 16 years; 52% male), initial imaging was CT in 58.5%; 53% had MRI <72 hours. 46% of baseline imaging comprised contrast-injection. CT-only patients were older, with larger hematomas and higher in-hospital mortality (all<0.05). ICH (48 ± 47 mL) was predominantly supratentorial (90%), with deep (52%) or lobar (frontal 28%) locations. MRI detected white matter hyperintensities (76%), lacunes (43%), infarcts (14%), acute ischemias (6%), and microbleeds (65%). CT identified an etiology in 50% vs. 80% for MRI (<i>p</i> < .001), mainly mixed cSVD (34%), arteriolosclerosis (23%), CAA (14%), and vascular malformations (7%) when based on MRI. Follow-up imaging <72 h was done in 42%, mostly CT.ConclusionsAlthough CT was more frequent, MRI was superior for early etiological assessment of spontaneous ICH, mainly identifying cSVD-related causes. Broader use of early cerebral MRI could contribute to optimizing ICH care by improving identification of mixed cSVD patients and might help prevent secondary bleeding. Prospective and standardized MRI use in the early phase of ICH will clarify its role.