# December 2025 – Case 2 - Link: https://isnr.in/december-2025-case-2/ - Published: 2025-12-08T02:08:07+05:30 - Author: ISNR ## CASE HISTORY 59-Year-old lady, a known case of chronic liver disease with portal hypertension presented with progressive left hemiparesis over three months. There was no history of fever/ weight loss/previous head injury. Plain CT Brain and CE-MRI Brain were done to evaluate the same. #### **Investigations** **LFT:** Bilirubin total – 1.3mg/dl, bilirubin direct – 0.7mg/dl, SGOT -102U/L, SGPT – 68U/L, ALP – 185U/L, Serum albumin – 4.8g/dl, serum globulin – 4.8g/dl, albumin: globulin – 0.46, PT- 17.3s, APTT- 36.6s (Deranged). **CRP- 19mg/L (raised),** **PLC and RBC counts are reduced**, TLC – 5560/cu.mm ( within normal limits). ## CASE CONTRIBUTED BY Dr. **Namitha Ajith Kumar**, Department of Radiology, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Anusha shree Thaneeru**, Department of Radiology, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Chirag G**, Department of Radiology, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Chaitra P. Adiga**, Consultant Radiologist, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Yashwanth A S**, Consultant Radiologist, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Lakshmikanth G N**, Consultant Radiologist, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Veekshit Shetty**, Consultant Neurosurgery, Manipal Hosipitals, Kanakapura Road, Bangalore. Dr. **Arati Kamble**, Consultant Microbiologist, Manipal Hosipitals, Kanakapura Road, Bangalore. ## DESCRIPTION * **A ****:**Axial section of plain CT brain shows a well defined hypodense lesion in the right middle frontal gyrus with extensive perilesional edema in the right frontal lobe white matter. * **B****and C **: The lesion shows central diffusion restriction. * **D:** Axial T2 sequence shows a well defined T2 hyperintense lesion seen in the right middle frontal gyrus with peripheral hypointense rim and extensive perilesional edema. * **E****:** Axial section of susceptibility weighted sequence shows peripheral blooming around the lesion with few microbleeds adjacent to the lesion. * **F:** Axial section of arterial spin labelling sequence shows no perfusion at the centre and periphery. * **G and H:** Axial section of pre-contrast T1 FS sequence and post-contrast T1 sequence showing peripheral enhancement on post contrast study. * **I: **Gram stain – No pus cells. No organisms seen. * **J:** Sediment smears from the fluid sample showed macrophages on a background of RBCs on Leishman stain. Pus culture report from specimen obtained from the showed no growth after 48hours of incubation. ![](https://isnr.in/wp-content/uploads/2025/12/case-of-the-month-december-2025-2- 1.jpg) ## **Diagnosis: Chronic Encapsulated Intracerebral Hematoma (CEIH)** #### **Discussion:** * CEIH is a **extremely rare form of intracerebral haemorrhage** with progressive Clinicoradiological features and is often **misdiagnosed** as abscess or tumors ^(1). * Intracerebral hematomas usually resolve spontaneously. Rarely, they become encapsulated and enlarge from repeated internal bleeding after a delay^(2). This expansion can cause neurological deficits and features of raised intracranial pressure. * Patients may also have progressive neurological deficits, such as weakness, visual deficit, behavioural changes, or dysphasia. Acute presentation with seizure can also occur.   * Associations of CEIH include, vascular malformations, coagulation disorders, post radiosurgery/ radiotherapy, post traumatic or spontaneous parenchymal hemorrhage and neoplasms^(3). * It can occur in **any age group, with a mean age of 44 years** and has been reported to occur in the cortical or subcortical area^(3). * Generally, the time course of CEICH is not strictly defined, however, CEICH is reported to occur **between 2 and 4 weeks after onset of ICH****^(3)****.** * CEIH is characterized by the presence of a **fibrotic capsule**, histologically resembling the outer capsule of chronic subdural hematoma and is thought to grow due to repeated bleeding from the new blood vessels in the capsule^(2,3). #### **Imaging:** * CT scan shows a well-defined hypodense lesion with clear borders, surrounding edema and mass effect^(1). * On MRI, it appears as hyperintense on T1 and T2 sequences with hypointense rim on T2 sequences. * Core of the lesion often shows bright signal intensity on DWI due to subacute blood products mimicking an Abscess. * The wall is uniform in thickness (measuring 1-3mm)^(2). SWI sequence demonstrates a ring like wall more clearly with low signal intensity^(2). Coexistence of these signs could distinguish CEIH from brain tumors and brain abscesses^(1). * The hematoma envelope (“ring”) is intact in CEIH, but the ring in tumors is often partially or completely missing and is of an uneven thickness^(1). * On post contrast study, the enhancement is often variable from  mild to no enhancement ^(2). * Although the outer membrane of the chronic encapsulated intracerebral hematoma is rich in small vessels, the density of the vessels may be much less than in a hypervascular tumor, therefore, the outer membrane of the hematoma does not show hyperperfusion on 3D-ASL^(1). #### **Management:** * To prevent recurrence of the hemorrhage originating from the capsule’s thin – walled capillaries, complete excision of the haematoma along with its capsule is mandatory. * However in our case, only aspiration was done due to diagnostic conspiracy & underlying coagulopathy, following which the aspirated contents were sent to lab which showed degenerative RBCs and no bacterial growth.    #### **Differential diagnosis:** * Cerebral abscess * Cystic intracerebral tumors #### **Conclusion:** * In a patient with history of slowly progressive neurological deficits and altered coagulation profile without any fever or raised counts  mandates to consider the possibility of CEIH over cerebral abscess. * On imaging, absent dual rim sign on SWI/T2, low signal on ASL and core T1 hyperintensity favoured CEIH. | **Chronic encapsulated intracerebral haematoma (CEIH)** | **Cerebral abscess** | **Cystic intracranial tumours** | | T1 hyperintense | T1 hypointense | T1 hypointense or hyperintense | | ASL shows hypointense rim | ASL may show bright rim | ASL often shows bright rim | | Diffusion restriction | Diffusion restriction | Variable diffusion restriction | | No double rim sign on T2/FLAIR | Double rim sign on T2/FLAIR | No double rim sign on T2/FLAIR | | Hemosiderin rim on SWI/T2 | May show hemosiderin rim | Glioblastomas may show thick irregular/broken hemosiderin rim | | May or may not show ring enhancement | Continuous smooth peripheral enhancement | Thick irregular peripheral or central enhancement | #### **REFERENCES :** 1. Zhou, B. (n.d.). **Imaging Diagnosis of Chronic Encapsulated Intracerebral Hematoma, a Comparison of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) characteristics** Sainan Cai 1 2. Kamide, T., Seki, S., Suzuki, K.-I., Aoki, T., Hirano, K.-I., Takahashi, M., & Nomura, M. (2016). **A chronic encapsulated intracerebral hematoma mimicking a brain tumor: Findings on arterial spin labeling of MRI**. The Neuroradiology Journal, 29(4), 273–276 3.  Shimizu, K., Sadatomo, T., Hara, T., Ohba, H., Yuki, K., & Kurisu, K. (2017). ** Frequency and predicting factors on chronic expanding intracerebral hematoma in spontaneous intracerebral hemorrhage**. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association, 26(7), 1541–1546.  4.  Marutani, A., Nagata, K., Deguchi, J., Nikaido, Y., & Kazuki, S. (2015). **A case of recurrent hemorrhages due to a chronic expanding encapsulated intracranial hematoma.** Case Reports in Neurology, 7(3), 173–180.