Hemorrhages into the brain occur unexpectedly and are often lethal events. Typical warning signs are not known; rarely a feeling of unsteadiness, dizziness or a tingling sensation can precede an intracerebral hemorrhage (ICH), but such symptoms do not have localizing value such as in ischemia, where stroke-like warning signs (transient attacks) can occur days or weeks before the onset of a stroke. Often enough only a history of elevated blood pressure is known. Thus, for most patients, it comes “out of the blue”. The volume of the hemorrhage into the brain is the most decisive prognostic component and when reaching a total volume (such as more than 60 ml within one cerebral hemisphere) that cannot be compensated by intracranial compartmental reserve capacity, the consequences are downward herniation of the medial temporal lobe and compression of the brainstem.

Primary intracerebral hemorrhage associated with hypertension most commonly occurs in deep brain structures (e.g. putamen, thalamus, cerebellum and pons). By contrast, primary intracerebral hemorrhages that occur in lobar regions, particularly in elderly patients, are commonly related to cerebral amyloid angiopathy but might also be associated with hypertension (Table 10.1). At many centers non-contrast CT is the imaging modality of choice for the assessment of intracerebral hemorrhage, owing to its widespread availability and rapid acquisition time. MRI has not been favored due to its higher costs and due to the fact that conventional T1-weighted and T2-weighted MRI pulse sequences are not sensitive to blood in the hyperacute stage.