Fig 1  a-c (top)    d-f  (bottom)

(a) Sagittal T1- weighted image shows an intra-axial lesion in the right temporoparietal region with signal characteristics suggestive of hemorrhage. (b) Coronal T2- weighted image shows a heterointense lesion with extensive perilesional edema.(c) Axial DWI image shows areas of diffusion restriction within the solid component.

(d) Axial ADC map shows corresponding low signal intensity. (e) Axial FLAIR image shows a heterointense lesion with extensive perilesional edema.(f) Axial SWI/GRE image shows susceptibility-related blooming, consistent with intralesional blood products.

Overall imaging appearance was interpreted as acute intraparenchymal hemorrhage. No contrast-enhanced sequences were performed.

October 2025 – CT Brain

Non-contrast CT of the brain demonstrated a hyperdense lesion in the right temporoparietal region with mild surrounding vasogenic edema. Given the history of trauma and prior MRI findings, the lesion was reported as a chronic resolving intraparenchymal hemorrhage (Figure 2).

Fig 2

Axial and coronal NCCT images show an ill-defined heterodense lesion in the right temporoparietal region with surrounding edema, compression of the right lateral ventricle, and leftward midline shift (~7.8 mm) with mild uncal herniation (red arrows), reported as chronic resolving intraparenchymal hemorrhage.

November 2025 – Follow-up CT Brain

Repeat non-contrast CT showed persistence of the hyperdense right temporoparietal lesion with minimal interval change in size or density. Despite the lack of expected radiological resolution, the diagnosis of resolving hemorrhage was maintained (Figure 3).

Figure 3

Axial and coronal NCCT images show a hypodense lesion with extensive perilesional edema, progressive mass effect, and increased midline shift (~13.1 mm) with features of subfalcine and uncal herniation.

December 2025 – CT Brain

The patient presented with altered sensorium. Non-contrast CT was performed and interpreted without access to previous imaging or reports. The scan demonstrated a heterogeneous intra-axial hyperdense lesion in the right temporoparietal region with disproportionate surrounding vasogenic edema and mass effect. On this sssessment - without the benefit of previous imaging findings, the imaging features raised suspicion of an underlying high-grade glioma rather than a simple hemorrhage (Figure 4).

Figure 4

Axial and coronal NCCT images show a heterogeneous intra-axial mass in the right parietotemporal region with marked edema and midline shift (~14 mm) with features of subfalcine and uncal herniation. No acute hemorrhage is seen. 

December 2025 

Subsequent contrast-enhanced MRI demonstrated a heterogeneous intra-axial lesion in the right temporoparietal region. The lesion showed mixed signal intensity on T1-weighted images, hyperintensity on T2-weighted and FLAIR sequences with extensive perilesional vasogenic edema, and intralesional blooming on susceptibility-weighted imaging, consistent with hemorrhage. Post-contrast T1-weighted images revealed irregular, heterogeneous enhancement. These findings were diagnostic of a hemorrhagic high-grade glioma (Figure 5 a-h).

Figure 5  a-d

Preoperative MRI brain (a) Sagittal T1-weighted image shows an iso-to-hypointense intra-axial lesion in the right parietotemporal region. (b) Axial T2 image shows a heterointense lesion with extensive perilesional edema with midline shift. (c) Axial DWI image shows areas of diffusion restriction within the solid component. (d) Axial ADC map shows corresponding low signal intensity.

Figure 5 e-h

(e) Coronal FLAIR image shows a heterointense lesion with extensive perilesional edema and uncal herniation. (f) Axial SWI image shows areas of internal susceptibility foci, consistent with intralesional hemorrhage. (g) Axial pre-contrast T1-weighted fat saturated image shows heterogeneous lesion with irregular margins.

January 2025 – MRI Brain 

Postoperative contrast-enhanced MRI of the brain demonstrated postsurgical changes in the right parietotemporal region with a resection cavity and surrounding edema. A small residual enhancing focus was noted along the margins of the resection cavity, suggestive of subtotal resection. There was interval reduction in mass effect and midline shift. No acute postoperative hemorrhage or infarct was identified (Figure 6 a-h).

Figure 6 a-d

(a, b) T1 and T2-weighted images show a postoperative resection cavity in the right parietotemporal region. (c) Axial DWI image shows areas of diffusion restriction in the residual solid component. (d) Axial ADC map with corresponding low signal intensity.

Discussion

Intratumoral hemorrhage is a well-recognized presentation of high-grade gliomas and accounts for a proportion of spontaneous intracerebral hemorrhages. Tumor-related neovascularity, endothelial proliferation, and necrosis weaken vascular integrity, predisposing these tumors to bleeding and often masking the underlying mass on initial imaging. High-grade astrocytomas are among the most frequently reported tumors associated with hemorrhagic presentation (Sarkar et al. [1], Chakraborti et al. [2]).

Temporal evolution of hemorrhage is a critical discriminator between benign hemorrhage and hemorrhagic neoplasm. Traumatic intraparenchymal hemorrhage typically demonstrates progressive reduction in size and density on follow-up imaging, eventually evolving into encephalomalacia. Persistence of hemorrhage without expected interval resolution, as seen in this case, is atypical and should prompt further investigation for an underlying lesion (Goyal et al. [3]).

This case also underscores the impact of cognitive biases in radiological interpretation. Anchoring bias, where early diagnostic impressions influence subsequent reporting, likely contributed to delayed diagnosis. Notably, when the December 2025 CT was interpreted independently, without reference to prior imaging or reports, the atypical features were immediately recognized and suspicion of glioma was raised. The role of cognitive bias and the importance of independent reassessment have been emphasized in radiology literature (Kundel and Nodine [4]).

MRI remains central to the evaluation of hemorrhagic brain lesions. Imaging features favoring neoplastic etiology include heterogeneous signal intensity, irregular or nodular enhancement, extensive vasogenic edema, and intralesional blooming on susceptibility-weighted imaging. While advanced MRI techniques such as perfusion imaging and spectroscopy may further aid characterization, histopathology remains the definitive diagnostic standard (Patil et al. [5]).

Conclusion

Intracerebral hemorrhage that fails to resolve as expected should not be presumed traumatic. Careful assessment of temporal imaging evolution, independent image interpretation, and appropriate use of contrast-enhanced MRI are essential to avoid delayed diagnosis of hemorrhagic high-grade gliomas.

References: 

1. Sarkar C, Mukhopadhyay S, Ralte AM. Hemorrhagic intracranial tumors: A clinicopathological study. Neurology India. 2004;52:448–452.

2. Chakraborti S, Mahadevan A, Yasha TC, et al. Intracranial hemorrhage as the presenting feature of brain tumors. Neurology India. 2011;59:872–876.

3. Goyal M, Mishra NK, Gaikwad SB. Imaging evaluation of hemorrhagic intracranial neoplasms. Indian J Radiol Imaging. 2001;11:67–74.

4. Kundel HL, Nodine CF. Errors in radiology revisited: Cognitive bias and perceptual pitfalls. Indian J Radiol Imaging. 2007;17:161–164.

5. Patil VM, Noronha V, Joshi A, et al. High-grade gliomas: Imaging features and management considerations. J Assoc Physicians India. 2016;64:54–60.