Blood -Fluid Level in a Spontaneous Intraparenchymal hematoma

Clinical History

The patient presented with sudden onset palpitation and mild limb weakness and was admitted in the indoor department of medicine after developing progressive weakness leading to hemiparesis, and underwent CT after 2 days. There was no history of any drug intake, anticoagents intake or previous such episode. The patient was normotensive.

Imaging Findings

NCCT head shows large hematoma with blood fluild level in the LT temporal lobe involving both grey and white matter with very minimal perihematomal oedema and mass effect on ventricles (Fig 1, 2).

Discussion

CT plays a significant role in evaluating patients with acute intracerebral haemorrhages. In non-traumatic patients, the features and location of the haematoma can help in determining the cause of the bleed. Intracerebral haematoma (ICH) usually presents on CT as areas of high density relative to the adjacent brain. Fluid-blood phenomena are rarely noted in ICH, however, it is a familiar finding in subdural and intraventricular haemorrhages. In intraparenchymal haemorrhage, clot formation takes place without sedimentation because of the absence of a potential space, thus the association of a fluid-blood level is uncommon in ICH. A blood-fluid level is defined as a region within the haematoma that has the upper compartment hypodense to the brain, lower compartment hyperdense to the brain and sharply horizontal interface between the upper and lower compartments [1]. Intracerebral blood-fluid interface has been reported in patients with ruptured arteriovenous malformations and metastatic melanoma and in recent bleed.
Intracerebral haematomas with a blood-fluid interface can be secondary to a coagulation defect preventing clot formation once it is formed. In vitro studies support the hypothesis that an intracerebral haemorrhage blood-fluid level reflects the inability to either form or maintain a clot matrix. The blood-fluid interface could be explained by this hypothesis. Gebel et al. reported that haemorrhages caused by coagulopathy are large and have mild peri-hematoma oedema. This would be consistent with the finding that the activity of clotting factors may be related to the formation of early peri-hematoma oedema [2]. In comparison to spontaneous ICH, thrombolysis-related ICHs have visible peri-hematoma oedema in <50% of the cases with spontaneous ICHs, and also had lower amounts of absolute and relative volumes of oedema. The blood-fluid level could also be due to coagulopathy when it is located in the centre of a haematoma with less peri-hematoma oedema. Mark J et al. noted that the probability of finding a fluid-blood level in an intracerebral haemorrhage of a patient with abnormal prothrombin time or partial thromboplastin time was 59%. The probability that there will be no fluid-blood level in a patient with a normal prothrombin time and partial thromboplastin time was 98% [3]. In our case, patient's prothrombin time (PT) and partial thromboplastin time was deranged (increased) on blood investigation performed after CT findings.

Patients with occult pathology have a very poor prognosis and require special attention and treatment. Therefore, an intracerebral hematoma with a blood-fluid level should warrant a thorough search for occult pathology.

Differential Diagnosis List

Final Diagnosis

Intraparenchymal hematoma with blood-fluid level (due to coagulation factor deficiency)

URL:	https://www.eurorad.org/case/13274
DOI:	10.1594/EURORAD/CASE.13274
ISSN:	1563-4086