A history of rapid onset of focal neurological signs is suggestive of ICH, especially if the individual has risk factors for bleeding - e.g. hypertension, a bleeding diasthesis, cocaine use, or anticoagulant therapy. Look for features of raised intracranial pressure - e.g. headache, vomiting, papilloedema and decreased level of consciousness.
Confirmation of suspected ICH is usually by CT or MRI. CT defines the size, location and site of a haematoma and other relevant criteria such as extension into the ventricular system, presence of surrounding oedema and herniation. Acute haematomas are well-defined by CT and show smooth borders. 'Burst lobes' may be described. Repeated CT may be used to track a worsening condition.
MRI is more useful for showing older haematomas and for characterising cavities formed by resolution of an ICH. It may also show arteriovenous malformation.
Angiography may reveal underlying vascular malformations and aneurysms. It is usually indicated in normotensive patients.
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