This chapter discusses the diagnosis, evaluation and management of intracranial hemorrhage. It describes types of intracranial hemorrhage, including subarachnoid hemorrhage (SAH), subdural hemorrhage (SDH), epidural hemorrhage (EDH) and intracerebral hemorrhage (ICH). Emergent non-contrast head CT is the cornerstone for detection of ICH. MRI is equally effective in identifying ICH and better at detecting predisposing underlying parenchymal or vascular anomalies. Emergency department management focuses on protecting cerebral perfusion by balancing the forces of mean arterial pressure (MAP) and intracranial pressure (ICP). Patients should be positioned with the head of the bed elevated to 30 degrees to support cerebral venous drainage to reduce ICP. The main goal of emergency management is to temporize ICP changes, avoid secondary insults (e.g., hypoxia and hypotension) and protect cerebral perfusion pressure (CPP) while expediting neurosurgical evaluation for possible life-saving surgical intervention.

This chapter provides an overview of the prevalence and associations, temporal evolution and prognostic significance of cerebral microbleeds (CMBs) in patients with cerebrovascular diseases. The spatial distribution of microbleeds, as markers of small vessel microhemorrhagic or microaneurysmal lesions, may be of particular interest in attempts to understand the causes of macroscopic intracerebral hemorrhage (ICH) in life. Cerebral amyloid angiopathy is an important cause of primary ICH, particularly of lobar location. Chronic hypertension has been repeatedly identified as a strong influence on the frequency and extent of CMBs, in patients with established stroke as well as in healthy subjects without stroke. Hypertension is an important risk factor for CMBs. As CMBs reflect the bleeding tendency of the brain through fragile microvascular walls, interest has increased in utilizing CMBs in risk stratification of hemorrhagic complications for patients with antithrombotic treatment.

The progress made by transitioning from axial imaging of soft tissue (with single-detector Computed Tomography (CT) scanners) to volumetric imaging (by multidetector CTs (MDCTs)) has revolutionized vascular studies. CT angiography (CTA) of the abdomen can truly alter management and dispositions. Leaking or dissecting abdominal aortas, along with similar lesions in the iliac vessels, are among the most anxiety-provoking diagnoses for the emergency medicine physician. The search for the cause of intractable chronic hypertension often includes a study to determine whether renal artery stenosis is present. CTA is well-suited to this task. CTA has been shown to be useful in both arterial and venous occlusion in the mesenteric circulation, and to demonstrate whether bowel injury from vascular compromise is present. Data acquisition of thrombus in the inferior vena cava (IVC) or its contributaries from the pelvis and proximal lower extremities can be useful in guiding therapy regarding thrombolysis versus stent placement.