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Acute non-traumatic intracerebral haemorrhage (ICH) has a poor prognosis and is the least treatable form of acute stroke. Although less common than acute ischaemic stroke, ICH causes greater premature loss of productive life years on a global scale due to its predilection to affect people at younger ages with devastating consequences. Prognosis from ICH is related to location, initial volume and speed of expansion of the haematoma, and associated intraventricular haemorrhage. Care in a specialised stroke or neurointensive care unit improves outcome. Surgical haematoma evacuation should be pursued as for patients with cerebellar haemorrhage with neurologic deterioration, hydrocephalus, orsd brainstem compression. Haematoma evacuation may be considered, as a life-saving measure, in patients with coma or large haematoma with mass effect. Minimally-invasive surgery in stable patients is of uncertain benefit and is being evaluated in RCTs. Clinicians should not routinely use haemostatic therapies where there is no evidence of coagulopathy or anticoagulant use. When coagulopathy is present, early corrective measures should be taken. Early moderate intensity BP lowering to a systolic BP target of 140 mmHg is reasonable. Medical therapies to reduce mass effect and intracranial pressure should not be used routinely, but hyperventilation and hypertonic saline or colloidal osmotic agents are reasonable in patients with imminent herniation as a bridge to definitive neurosurgical intervention. Corticosteroids should be avoided. Novel neuroprotective approaches hold promise.
The cerebral microbleed (CMB) mimics form two types: those that contain blood products and those that do not (resembling CMBs because of shared signal intensity and morphology on gradient-recalled echo (GRE) MRI). This chapter describes both types, and outlines how these can be differentiated from true CMBs. It suggests a topographical approach to the recognition of CMB mimics on brain imaging. The GRE sequences used in the detection of CMBs are sensitive not only to blood breakdown products (deoxyhemoglobin, methemoglobin, hemosiderin and ferritin) but also to other paramagnetic substances such as calcium, manganese and iron, all of which may appear as foci of low signal. In lobar regions of the brain, common CMB mimics include vascular flow voids and hypointensities arising from partial volume artefact. The development of susceptibility-weighted imaging (SWI) has improved the detection of structures containing extravascular blood products, as well as those containing venous deoxygenated blood.