Simultaneous bilateral hypertensive putaminal or thalamic hemorrhage: case report and systematic review of the literature

Abstract

Simultaneous multiple hypertensive intracranial hemorrhage is rare, and its mechanism is unclear. We report a case of simultaneous hypertensive bilateral thalamic hemorrhage. A 58-year-old man presented with sudden mild right hemiparesis. Computed tomography 1 hour after the onset showed bilateral thalamic hemorrhage. Gradient-echo T2*-weighted magnetic resonance imaging showed 17 microbleeds. The patient was treated with medication, discharged home, and achieved a modified Rankin scale of 1 at 3 months from the onset. Additionally, by systematically searching in PubMed, we found 41 cases of simultaneous bilateral hypertensive putaminal or thalamic hemorrhage, including our case: 18 bilateral putaminal, 12 bilateral thalamic, and 11 unilateral putaminal and contralateral thalamic hemorrhage. Symmetric hemorrhage occurred more frequently than expected ratios of hemorrhage occurring randomly in terms of location (p=0.013; Fisher's exact test). These new findings raise the hypothesis that patients may have symmetrically vulnerable vessels. Such conditions would result in coincidence or subsequent rupture of perforating arteries or micro-aneurysms by increased blood pressure and cause symmetric hemorrhages. Studies on the distribution of microbleeds may address these issues.

Multiple Intracerebral Hemorrhages in an Old Patient with Rheumatoid Arthritis

“…The finding of symmetric simultaneous hypertensive putaminal or thalamic haemorrhages suggests that patients may have symmetrically vulnerable vessels [14].…”

Delayed Consecutive Contralateral Thalamic Hemorrhage after Spontaneous Thalamic Hemorrhage

“…Putaminal or thalamic hemorrhages are most frequently observed in cases with primary bilateral simultaneous bleedings 20). In previous report, simultaneous or subsequent bilateral thalamic hemorrhages have been reported from 12 up to19 cases 6)7)11). And most of them have been reported in the Asian countries.…”

“…Primary multiple intracranial hemorrhage (ICH) without underlying causes of abnormal vascular lesions, trauma or coagulopathy have been reported with an incidence rate ranging from 0.75-4.7% in patients with spontaneous ICH 6)14)17). Putaminal or thalamic hemorrhages are most frequently observed in cases with primary bilateral simultaneous bleedings 20).…”

Asia Pacific Stroke Conference 2016. Abstracts of the Annual Conference of theAsia Pacific Stroke Organization (APSO) Combined with Stroke Society of Australasia, Brisbane, Qld., Australia, July 14-17, 2016: Abstracts

“…Background and Rationale: TIA and minor stroke patients with Diffusion Weighted Imaging (DWI) lesions have worst prognosis than those without (Sato, 2014;Merwick, 2010). Clinical features associated with DWI lesions in this population are well described (Kono, 2014), but whether CT Perfusion (CTP) can predict subsequent DWI-evident tissue injury is unclear. We sought to study the prevalence of DWI lesions in TIA and minor stroke patients according to CTP result, and whether thrombolysis (IVtPA) alters this association.…”

“…The majority of spontaneous ICHs are associated with hypertension, however various factors may be considered including a deep cerebral vein thrombosis, neoplasm, intravenous administration of tissue plasminogen activator and coagulopathies. Although the mechanism of bilateral simultaneous hypertensive ICH remains unclear, there are two currently proposed mechanisms, the coincidental rupture and the subsequent rupture of bilateral micro-aneurysms or perforating arteries (Kono and Terada, 2014). Chronic hypertension can cause hyaline degeneration of the perforating vessels which would be likely to be symmetrical.…”