Hemorrhage on MRI

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~~Ageing blood~~Haemorrhage on MRI

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~~The~~Haemorrhage on MRI has highly variable imaging characteristics of ~~blood~~that depend on ~~MRI~~ ~~can be variable and change with~~both the age of the blood and the sequence. Although MRI is often thought of as not being sensitive to acute haemorrhage, this is not, in fact, true ^5,7. The appearance of haemorrhage will, however, be different at different times.

Physiology

The factors that affect the appearance of haemorrhage on MRI include the state of the blood (e.g. has it formed a retracted clot or is it anticoagulated) as well the oxygenation state.

The oxygenation state of haemoglobin has a tremendous effect on the imaging effects of blood.

Oxyhaemoglobin is only weakly diamagnetic, whereas deoxyhaemoglobin is strongly paramagnetic, and results in substantial signal loss on T2* weighted sequences, such as susceptibility weighted imaging, and blooming artefact.

In arterial blood 95% of haemoglobin is the oxyhaemoglobin form and thus acute arterial haemorrhage has relatively little signal loss ⁶.

Venous blood, on the other hand, has only 70% oxyhaemoglobin. The 30% of deoxyhaemoglobin, therefore, has a greater immediate effect on T2* weighted sequences.

Regardless of arterial or venous source, with time, the proportion of haemoglobin in the deoxyhaemoglobin increases and thus the paramagenetic effects become dominant. Simultaneously the amount of water in the haematoma reduces as it is resorbed.

Stages

In general, five stagesof haematoma evolution are recognised:

hyperacute
- intracellular oxyhaemoglobin
- isointense on T1
- isointense to hyperintense on T2
acute (1 to 2 days)
- intracellular deoxyhaemoglobin
- T2 signal intensity drops (T2 shortening)
- T1 remains intermediate-to-low
early subacute (2 to 7 days)
- intracellular methaemoglobin
- T1 signal gradually increases (T1 shortening) to become hyperintense
late subacute (7 to 14-28 days)
- extracellular methaemoglobin: over the next few weeks, as cells break down, extracellular methaemoglobin leads to an increase in T2 signal
chronic (>14-28 days)
- periphery
  - intracellular haemosiderin
  - low on both T1 and T2
- ~~center~~centre
  - extracellular haemichromes
  - isointense on T1, hyperintense on T2

Remembering these may be facilitated by this ageing blood on MRI mnemonic.

Practical points

extracranial blood products age differently from intracranial blood products, and extracranial haematomas often have a heterogeneous appearance, confounding attempts at reliably dating the age of an extracranial haemorrhage ^3,4
subacute and chronic blood~~/haemorrhage~~ appears hypointense and blooms ~~black~~ on MRI T2*
~~GRE~~ weighted sequences (e.g. susceptibility weighted imaging ~~is also highly sensitive to old haemorrhage and is seen as haemosiderin staining~~(SWI))

~~See also~~

~~ageing blood on MRI (mnemonic)~~

-<p>The imaging characteristics of <a href="/articles/stages-of-blood-on-t1t2-mri-and-t2-imaging"><strong>blood on MRI</strong></a> can be variable and change with the <a href="/articles/stages-of-blood-on-t1t2-mri-and-t2-imaging">age of the blood</a>.</p><p>In general, five <a href="/articles/ageing-blood-on-mri-mnemonic">stages<strong> </strong>of haematoma</a> evolution are recognised:</p><ol>
+<p><strong>Haemorrhage on MRI</strong> has highly variable imaging characteristics that depend on both the age of the blood and the sequence. Although MRI is often thought of as not being sensitive to acute haemorrhage, this is not, in fact, true <sup>5,7</sup>. The appearance of haemorrhage will, however, be different at different times. </p><h4>Physiology</h4><p>The factors that affect the appearance of haemorrhage on MRI include the state of the blood (e.g. has it formed a retracted clot or is it anticoagulated) as well the oxygenation state. </p><p>The oxygenation state of haemoglobin has a tremendous effect on the imaging effects of blood. </p><p>Oxyhaemoglobin is only weakly diamagnetic, whereas deoxyhaemoglobin is strongly paramagnetic, and results in substantial signal loss on T2* weighted sequences, such as <a href="/articles/susceptibility-weighted-imaging-1">susceptibility weighted imaging</a>, and <a href="/articles/blooming-artefact-mri">blooming artefact</a>. </p><p>In arterial blood 95% of haemoglobin is the oxyhaemoglobin form and thus acute arterial haemorrhage has relatively little signal loss <sup>6</sup>. </p><p>Venous blood, on the other hand, has only 70% oxyhaemoglobin. The 30% of deoxyhaemoglobin, therefore, has a greater immediate effect on T2* weighted sequences. </p><p>Regardless of arterial or venous source, with time, the proportion of haemoglobin in the deoxyhaemoglobin increases and thus the paramagenetic effects become dominant. Simultaneously the amount of water in the haematoma reduces as it is resorbed. </p><h4>Stages</h4><p>In general, five stages <strong> </strong>of haematoma evolution are recognised:</p><ol>
~~-<li>center<ul>~~
+<li>centre<ul>
~~-</ol><h4>Practical points</h4><ul>~~
+</ol><p>Remembering these may be facilitated by this <a href="/articles/ageing-blood-on-mri-mnemonic">ageing blood on MRI mnemonic</a>.</p><h4>Practical points</h4><ul>
~~-<li>blood/haemorrhage appears hypointense and blooms black on MRI T2*</li>~~
~~-<li>~~
~~-<a href="/articles/gradient-echo-sequences-1">GRE</a> imaging is also highly sensitive to old haemorrhage and is seen as haemosiderin staining</li>~~
~~-</ul><h4>See also</h4><ul><li><a href="/articles/ageing-blood-on-mri-mnemonic">ageing blood on MRI (mnemonic)</a></li></ul>~~
+<li>subacute and chronic blood appears hypointense and <a href="/articles/blooming-artefact-mri">blooms</a> on MRI T2* weighted sequences (e.g. <a href="/articles/susceptibility-weighted-imaging-1">susceptibility weighted imaging (SWI)</a>)</li>
+</ul>

References changed:

6. Bren K, Eisenberg R, Gray H. Discovery of the Magnetic Behavior of Hemoglobin: A Beginning of Bioinorganic Chemistry. Proc Natl Acad Sci USA. 2015;112(43):13123-7. <a href="https://doi.org/10.1073/pnas.1515704112">doi:10.1073/pnas.1515704112</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26508205">Pubmed</a>
7. Kidwell C. Comparison of MRI and CT for Detection of Acute Intracerebral Hemorrhage. JAMA. 2004;292(15):1823. <a href="https://doi.org/10.1001/jama.292.15.1823">doi:10.1001/jama.292.15.1823</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15494579">Pubmed</a>

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