Intraparenchymal haemorrhage with fluid-blood levels

Clinical: 

  • A 50-year old lady
  • She has underlying end stage renal failure and hypertension
  • Admitted for dengue fever, complaint of headache
  • CT brain on admission was normal
  • Clinically there was no bleeding tendency
  • Platelet: 18, INR= 3.3, APTT >300.
  • Three days later had a fall in bathroom preceded by worsening headache
Non-contrast CT brain on the day of admission in axial plane
Non-contrast CT scan of the brain in axial plane 3 days later

CT scan findings:

  • There are multifocal intraparenchymal haemorrhages in both cerebral hemispheres
  • The largest are on the right side causing peripheral oedema and midline shift towards the left. There is also mass effect upon the ipsilateral lateral ventricle.
  • Many of these hemorrhages demonstrate fluid-blood levels which may be associated with bleeding from a coagulation disorder or anticoagulation.

Radiologic diagnosis: Acute intraparenchymal haemorrhages with blood fluid levels

Discussion:

  • Fluid-fluid level also described as blood-fluid level or sedimentation level in intracranial haemorrhage can be seen on CT or MRI.
  • This is associated with patients who have coagulopathy or who are receiving anticoagulation therapy. These can prevent the formation or lysis of a blood clot, resulting in this appearance.
  • On noncontrast head CT, fluid levels within the hematoma are associated with¬† an increased risk of expansion.
  • It may rarely be seen in patients with normal coagulation parameters, probably reflecting the fact that the PT/INR does not capture all patients with coagulopathy.
  • Higher intensity anticoagulation with increasing PT/INR is associated with a higher likelihood of blood-fluid levels, but many patients with fluid levels may only have mild to moderate PT/INR elevation.
  • As the coagulopathy is reversed, the bleeding stabilizes, fluid levels disappear, and the hematoma is eventually resorbed.

 

 

Author: radhianahassan