## Investigation of Choice in Acute Intracerebral Hemorrhage **Key Point:** After non-contrast CT confirms hemorrhage, CT angiography (CTA) and CT perfusion (CTP) are the standard next investigations in acute ICH to identify underlying vascular lesions and assess tissue viability. ### Why CT Angiography + Perfusion? Once ICH is confirmed on plain CT, the clinical priorities are: 1. **Identify secondary causes** — CTA detects aneurysms, arteriovenous malformations (AVMs), and vasculopathy 2. **Assess hematoma expansion risk** — CTP identifies hypodense (ischemic) penumbra and active extravasation 3. **Guide urgent intervention** — findings may warrant neurosurgical consultation, hemostasis, or ICU monitoring ### Role of Each Investigation | Investigation | Role in ICH | Timing | |---|---|---| | **CT angiography** | Detects aneurysm, AVM, cavernoma, vasculitis | Immediate after plain CT | | **CT perfusion** | Identifies active bleeding (contrast extravasation), ischemic tissue | Concurrent with CTA | | **Transcranial Doppler** | Assesses cerebral autoregulation, detects vasospasm | Not acute; used for monitoring | | **Conventional angiography** | Gold standard for vascular lesions but invasive | Reserved for CTA-inconclusive cases or therapeutic intent | | **MRI with GRE** | Excellent for chronic/subacute hemorrhage, microhemorrhages | Not first-line in acute phase; patient may be unstable | **High-Yield:** In this patient with intraventricular extension and young-to-middle age, CTA is essential to exclude aneurysm or AVM before considering surgical evacuation. **Clinical Pearl:** CTA has >95% sensitivity for aneurysms ≥3 mm and is non-invasive; it has largely replaced conventional angiography as the first-line vascular imaging in acute ICH. [cite:Harrison 21e Ch 296]
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