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IV. Spontaneous Intracerebral Hemorrhage

F. CSF Changes

CSF may be bloody because the hemorrhage may rupture directly into the subarachnoid space or intraventricular blood may enter the lumbar subarachnoid space via fourth ventricular outlet foramina.

G. Pathological Changes   

The hemorrhage produces a large cavity filled with clot. This is a highly destructive, space-occupying lesion.  Uncal herniation may occur with brainstem compression and secon­dary (Duret) brainstem hemorrhages. In cases of less severe hemorrhage, resolution may be associated with marked clinical improvement. The hemorrhage may expand over time, either because of continued bleeding or mechanical disruption of surviving vessels. Both vascular and cytotoxic edema may contribute to the clinical picture (see image).

A massive hemorrhage is seen. The cause of death was herniation leading to Duret hemorrhages in the brainstem. Note the cingulate gyrus herniation above the corpus callosum and the midline shift. Click here to enlarge