Yield of MRI in patients with spontaneous deep intracerebral hemorrhage

Hypertensive hemorrhage is the most common type of nontraumatic intracerebral hemorrhage (ICH), and it characteristically originates in deep structures, particularly the basal ganglia, internal capsules, thalami, brainstem, and cerebellum. While advanced imaging modalities like MRI can help uncover culprit lesions in cases of unexplained ICH, we hypothesized that the yield of brain MRI would be low in patients with spontaneous deep intracerebral hemorrhage.

With IRB approval, we retrospectively reviewed cases of deep ICH at a single tertiary care academic center over a 5-year period and excluded cases with a known cause for hemorrhage. Patient history and demographics, initial blood pressure, and the results of the initial noncontrast head CT and subsequent imaging studies were recorded.

222 patients met study inclusion criteria, with a median age of 67 and 43.2% female sex. 188 patients (84.7%) had a history of hypertension, while 14 (6.3%) had a urine drug screen positive for cocaine or amphetamines during their hospital admission. The majority of hemorrhages were centered in the basal ganglia or internal capsules (116, 52.3%). Brain MRI was obtained for 120 (54.1%) of cases at a median interval of 0.97 days following the initial head CT, and of these studies, 85 (70.8%) included postcontrast imaging. Only 1 MRI study (0.8%) identified a culprit lesion adjacent to a cerebellar hematoma, which was later found to represent a pilocytic astrocytoma. 33.8% of patients overall met the modified Hong Kong Rule. Of the 77 MRIs performed in patients not meeting the modified Hong Kong Rule, 0 revealed a culprit lesion.

Brain MRI obtained in the acute evaluation of patients with spontaneous deep intracerebral hemorrhage rarely uncovers a culprit lesion. Routine ordering of MRI in this cohort should be reconsidered, particularly in patients not meeting the modified Hong Kong Rule.