Fortuitous scan documentation of the
development of an intracerebral
hematoma
Case report
XAVIER J. RICCOBONO, M.D., AND STEWART Po CHASE, M.D.
Department of Radiology, Ohio State University, College of Medicine,
Columbus, Ohio

HE presence of an intracerebral hematoma can be correctely and reliably
demonstrated in a majority of cases by
scintillation scanning of the brain. 2-~ The radiotracer and instrumentation appear to be
less important than the timing of the scan. 1,~
Optimal delineation of the lesion occurs in
the 2nd and 3rd weeks following the insult.
Operative data indicate that the concentration of isotope occurs not in the hematoma
itself but in the adjacent compressed and
damaged brain tissue? This damage and peripheral reaction require time to develop, explaining the high positivity of scans 1 to 2
weeks after the event.
We witnessed the development of an intracerebral hemorrhage in our laboratory
during the actual process of brain scanning.
An initial brain scan was negative. A second
brain scan initiated within 15 minutes of
completion of the first, and following a grand
mal seizure by the patient, revealed a
densely radioactive intracerebral mass. Following surgical exploration and evacuation
of a hematoma, the scan returned virtually
to normal.

T

Case Report
A 59-year-old woman was admitted to the
hospital following a 24-hour history of dysarthria, somnolence, and right-sided weakI. Neurosurg. / Volume 33 / July, 1970

ness. There was no fever, headache, or neck
stiffness. The patient had a 4-year history of
hypertension and was being followed regularly in the hypertensive clinic, and being
treated with chlorthiazide, reserpine, and
phenobarbital.
Examination. The patient was oriented,
slightly lethargic, and dysarthritic. Her blood
pressure was 240/130, pulse 73, respiration
18, and temperature 98.6. Positive physical
findings were limited to the neurological examination. There was moderate muscle
weakness on the right side, and slightly diminished sensitivity to fine touch and pinprick on the right side of the body below the
neck. The deep tendon responses and cranial
nerve function were normal. The admission
diagnosis was infarct of the left internal capsule infarct with hypertension.
Approximately 24 hours after admission,
a brain scan was performed. The scan consisted of the four conventional projections
performed on a Nuclear Chicago Pho/Dot,
Model 1735, with a 3-inch crystal, using a
19-hole focusing collimator. Scanning was
begun 1 hour after the injection of 10 mCi of
Technetium-99m pertechnetate, and was
completed at 2 p.m. Figure 1 shows the anterior and right lateral projections on this
scan, which were felt to be essentially normal. Immediately after the study was corn79

Xavier J. Riccobono and Stewart P. Chase

Fro. 1. Initial scan done 24 hours after admission,
interpreted as essentially negative.

Fro. 2. Second scan started 15 minutes after
completion of the first scan. The patient's convulsion occurred between the first and second
scans. There is now a 7-cm spherical concentration of radioactivity in the right frontal lobe.

pleted, the patient suffered a grand mal
convulsion which lasted about 1 minute. Following the convulsion the patient remained
dull, with a fixed and dilated right pupil and
a constricted left pupil. At 2:15 p.m. another
brain scan was begun (Fig. 2) which demonstrated a 7-cm spherical lesion of maximal
radioactivity in the right frontal lobe. The
scan was interpreted as an acute intracerebral hemorrhage. Subsequently, a right retrograde brachial angiogram was performed
which demonstrated an avascular mass in
the right fronto-parieto-temporal area, which
was felt to represent an intracerebral hematoma.
Operation. The patient underwent a right
craniotomy 12 hours later, and a large intracerebral hematoma was found in the right
frontotemporal area. Approximately 150 cc
of blood were evacuated. A repeat brain
scan (Fig. 3) performed on the 7th postop-

erative day demonstrated only scant radioactivity at the site of the lesion. The patient has
remained comatose since surgery.

80

Discussion
T h e r e is little question that the hemorrhage indeed occurred in the interval between the two scans. Occasionally, lesions
accrete radionuclides at a slow rate; however, in this case the first scan (Fig. 1) was
clearly negative and the second strikingly
positive. The radiodensity of the lesion was
maximal in relation to the anatomical vascular structures in the second scan (Fig. 2).
Only 15 minutes elapsed between the end of
the first scan and the beginning of the second.
Brain lesions that accrete radioactivity do
so slowly, in a gradual rather than precipitous manner, and rarely achieve maximal radiodensity. Also, the clinical events coincide
g. Neurosurg. / Volume 33 / July, 1970

Intracerebral hematoma
vascular structures. This is unlike the usual
demonstration of intracerebral hematoma
where radionuclide accretion occurs in the
adjacent compressed brain tissue and only
after an interval of 3 to 14 days. 1,~
Sunllnsty

The development of an intracerebral hemorrhage during a brain scanning procedure
has been reported and discussed.

FIG. 3. Third scan performed on the 7th postoperative day following evacuation of an intracerebral hematoma. The increased concentration
of isotope in the parietal convexity is related to
the surgical procedure.

with the scan findings.
In this case, the radioactivity was apparently within the hematoma itself, its activity
being comparable to that of the surrounding

I. Neurosurg. / Volume 33 / July, 1970

References
1. BOURJAT, P., DALBUNO, S., and ESCUDERO,
L. Focalisation
gamma-encephalographique
des hematomes intracerebraux difficultes du diagnostic etiologique. Revue Oto-Neuro-Ophthal., 1967, 39:374-380.
2. CIRIC, I. S., QUINN, J. L., III, and BucY, P. C.
Mercury-197 and technetium-99m brain scans in
the diagnosis of non-neoplastic intracranial lesions. J. Neurosurg., 1967, 27:119-125.
3. OJEMANN, R. G., ARONOW, S., and SWEET,
W . H . Scanning with positron-emitting radioisotopes: aneurysm, arteriovenous malformation
and intracerebral hemorrhage. J. Neurosurg.,
1965, 22:489-498.
4. OVERTON, M. C., III, HAYNIE,T. P., and SNODGRASS, S. R. Brain scans in non-neoplastic lesions. J. Am. med. Ass., 1965, 191:431436.
5. WILLIAMS, L. J., and BEILER, D. D. Brain
scanning in non-tumorous conditions. Neurology, Minneap., 1968, 16:1159-1166.

Received for publication November 7, 1969.
Address reprint requests to: Xavier J. Riccobono, M.D., The Ohio State University Hospitals,
Department of Radiology, College of Medicine,
410 West 10th Avenue, Columbus, Ohio 43210.

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