Cerebral microhemorrhage

Changed by Rohit Sharma, 7 Mar 2024

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Cerebral microhaemorrhages, or cerebral microbleeds,are small focal intracerebral haemorrhages, often only visible on susceptibility-sensitive MRI sequences.

Pathology

Common aetiologies

cavernous malformations ^1,8
- especially Zabramski classification type IV malformations
- causes include multiple (familial) cavernous malformation syndrome and post-cerebral radiotherapy
cerebral amyloid angiopathy^1,8
- typically involves the grey-white matter junction; usually spares the basal ganglia
chronic hypertensive encephalopathy ^1,8
- typically involve the basal ganglia, thalami, brainstem, cerebellum and corona radiata
diffuse axonal injury (DAI) and other trauma ^1,8
- typically involves the grey-white matter junction, splenium of the corpus callosum, and dorsolateral brainstem

Less common aetiologies

acute haemorrhagic leukoencephalitis (AHLE) ⁸
amyloid related imaging abnormalities (ARIA-H) ¹⁶
cathepsin A-related arteriopathy with strokes and leukoencephalopathy (CARASAL) ^29,30
cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) ^1,8
- microhaemorrhages have been reported to occur in 25–70% of cases without a characteristic distribution
cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) ^20,21
cardiac bypass for surgery ^15,31
cerebral hyperperfusion syndrome ¹¹
cerebral vasculitis (primary or secondary) ^1,8
- microhaemorrhages usually located at the corticomedullary junction
COL4A1 brain small-vessel disease ^5,8
- microhaemorrhages have been reported in up to 53% of cases, characteristically in the centrum semiovale, deep gray matter, or brainstem ^5,8
Fabry disease ^35,36
haemorrhagic micrometastases ^1,8
- especially melanoma or renal cell carcinoma
hypoxia and/or being critically ill (e.g. acute respiratory distress syndrome, high-altitude ~~exposure~~cerebral oedema, COVID-19) ^8-10,39
immune effector cell-associated neurotoxicity syndrome (ICANS) ³²
intracranial embolism
- fat embolism
  - usually from fractures ^4,8,14
- gas embolism ^6,7
  - many causes including: intravenous catheter placement, decompression sickness, extracorporeal membrane oxygenation, hydrogen peroxide ingestion, etc.
- septic embolism
  - usually from infective endocarditis ^3,8
intracranial infection (e.g. cerebral malaria, mycotic aneurysm, dengue encephalitis, HSV encephalitis) ^8,37,38
intravascular lymphoma ^8,17
linear scleroderma ²⁵
moyamoya disease and moyamoya syndrome ^22,23
neurosarcoidosis ^12,13
pontine autosomal dominant microangiopathy with leukoencephalopathy (PADMAL) ^27,28
posterior reversible encephalopathy syndrome (PRES) ⁸
progressive facial hemiatrophy (PFHA) ^1,8
radiation-induced cerebral vasculopathy ^1,8
retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S) ^33,34
Sneddon syndrome ^18,19
thrombotic microangiopathies (e.g. haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP)) ⁸

Radiographic features

MRI

Cerebral microhaemorrhages are only seen on MRI and are only seen on susceptibility weighted T2* sequences such as gradient-recalled echo (GRE) and susceptibility weighted imaging (SWI) ²⁴.

They appear as conspicuous 2-10 mm punctate regions of signal drop out with blooming artifact ²⁴. This blooming grossly overestimates the size of the lesions, thus they are usually inapparent on other MRI sequences and CT ²⁴.

Differential diagnosis

artificial heart valve metallic emboli (very rare) ⁸
flow voids of veins ⁸
intracranial calcification ⁸
punctate regions of signal loss in chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) ²⁶
pneumocephalus (very rare without preceding surgery) ²

-<li>hypoxia and/or being critically ill (e.g. <a href="/articles/acute-respiratory-distress-syndrome-1">acute respiratory distress syndrome</a>, high-altitude exposure, <a href="/articles/covid-19-4">COVID-19</a>) 8-10</li>
+<li>hypoxia and/or being critically ill (e.g. <a href="/articles/acute-respiratory-distress-syndrome-1">acute respiratory distress syndrome</a>, <a href="/articles/high-altitude-cerebral-oedema" title="high-altitude cerebral oedema">high-altitude cerebral oedema</a>, <a href="/articles/covid-19-4">COVID-19</a>) 8-10,39</li>

References changed:

39. Hackett P, Yarnell P, Weiland D, Reynard K. Acute and Evolving MRI of High-Altitude Cerebral Edema: Microbleeds, Edema, and Pathophysiology. AJNR Am J Neuroradiol. 2019;40(3):464-9. <a href="https://doi.org/10.3174/ajnr.A5897">doi:10.3174/ajnr.A5897</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30679208">Pubmed</a>

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