Fact-sheet: Hematoma of brain


Updated on 04/09/2026 at 12:26 PM

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Definition

Hematoma of brain refers to the occurrence of hemorrhage within the supratentorial or (more rarely) infratentorial brain parenchyma.

50% complicate hypertension.
Other predisposing causes: anticoagulation, chronic alcoholism, amyloid angiopathy, cerebral venous thrombosis, herpetic encephalitis, post-traumatic, hemorrhagic tumor, malformation (cavernoma, AVM), preeclampsia, parathion poisoning.

Remote cerebellar hemorrhage is a rare condition following supratentorial craniotomy. This diagnosis should be considered postoperatively, especially in the absence of anticoagulation or hypertensive crisis

CT

Spontaneous hyperdensity, homogeneous, round or oval, with well-defined margins.
Density: 50 to 100 HU. Maximum density between H6 and H9.
Indirect signs (related to the volume of the Hematoma): mass effect on adjacent structures, hydrocephalus, intraventricular hemorrhage, cerebral herniation, etc.
Beware of special cases:
- Iso- or hypodense Hematoma in case of anemia (< 10 g/dl hemoglobin).
- Heterogeneous Hematoma: clot in the process of forming, clot fragmentation, repeat bleeding.
From D3 to D10: less well-defined margins, iso- then hypodense.
Progressive resolution from periphery to center with a decrease in density of 0.7 ± 0.3 HU per day.
Note that the overall diameter of the lesion increases = peri-Hematoma: expected increase in mass effect without any real increase in bleeding.
After 10 days: variable evolution over time.
Hematoma becomes isodense around the 3rd week then hypodense around the 4th week.
Ring enhancement after injection.
Long term:
Decrease in the volume of the cavity, with density similar to CSF.
Persistence of ring enhancement for several months.

MRI

More sensitive than CT (particularly for detecting hemosiderin deposits, markedly hypointense on T2*-weighted sequences).
Evolution of the Hematoma:

  • H2-H3: oxyhemoglobin
  • H3-H24: deoxyhemoglobin then methemoglobin: strong magnetic susceptibility
  • > M1: hemosiderin

Signal evolution:

  • Hyperacute stage (3 to 6h): isointense on T1 / iso- to hyperintense on T2
  • Acute stage (24 to 48h): isointense on T1 / hypointense on T2
  • Subacute stage (> 3 days): hyperintense on T1 / hyperintense on T2 (± peripheral hypointense rim)
  • Chronic stage (> a few months): hypointense on T1 / hypointense on T2 (± hyperintense rim).

T2-Flair sequence is highly sensitive in the acute phase and useful for perilesional edema.
T2*: sensitive to local magnetic field changes, hypointense rim at all stages.
Note that on diffusion, blood causes a decrease in ADC.

Vascular intervention

Angiography: may be part of the etiologic workup depending on the clinical context.

Management

Further etiologic workup (CT angiography/MR angiography/angiography) is necessary only if:

  • patient < 50 years old with a Hematoma of any location
  • patient > 50 years old with a lobar Hematoma.
  • = everyone EXCEPT a patient over 50 years old with hypertension and a deep Hematoma.

Note:

  • if an etiologic MRI workup is needed: it should be performed before day 3 (before the appearance of T1 hyperintensity, which would prevent proper assessment of any enhancement) or repeated after 3 months if the initial workup is unrevealing.
  • Between day 3 and 3 months: MRI will not be able to rule out an underlying tumoral cause!

Classification

Multiple etiologies:

  • Hypertension
  • Vascular malformations
  • Arteriovenous malformations
  • Aneurysms
  • Arteriovenous fistulas
  • Amyloid angiopathy
  • Brain tumors (including cavernomas)
  • Stroke
  • Venous ischemia
  • Toxic, drug-induced, infectious, and autoimmune angiopathies
  • Coagulation disorders
  • Antithrombotic therapy