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Neurology India, Vol. 56, No. 1, January-March, 2008, pp. 100-101 Letter To Editor Simultaneous thalamic and cerebellar hypertensive hemorrhages Balasubramaniam Srikant, Nadkarni TrimurtiD, Goel Atul Department of Neurosurgery, King Edward Memorial Hospital, Seth G.S. Medical College, Parel, Mumbai - 400 012, Maharashtra Date of Acceptance: 12-May-2007 Code Number: ni08031 Sir, Hypertensive intracranial hemorrhages are generally located in defined sites and have a relatively typical pattern of extension. We report an unusual case where there were simultaneous spontaneous thalamic and cerebellar hemorrhages in a patient with known hypertension. Presence of two discrete and unconnected clots is rare in hypertensive bleeds and only isolated cases have been recorded in the literature. [1] A 60-year-old male, a known hypertensive on irregular drug treatment, was admitted with sudden onset giddiness, left hemiplegia and transient unconsciousness. When admitted, 28 h after the ictus, his blood pressure was 170/100; he was in a drowsy clinical state, obeyed only very simple commands and had dense left-sided spastic hemiplegia. Computerized tomography of the brain demonstrated relatively large intracranial hemorrhages in the right thalamus and left cerebellum [Figure - 1]A,B. There was intraventricular extension. The hemorrhages in the thalamus and in the cerebellum were not connected with each other. The cerebellar hematoma was evacuated by a suboccipital craniectomy. The patient was neurologically stable following the operative procedure. However, on second postoperative day he became unconscious and developed tachypnoea. Postoperative scan confirmed evacuation of the cerebellar clot. The patient expired on the fourth postoperative day. The simultaneous occurrence of intracranial hemorrhages in different arterial territories is a rare clinical entity. [2] Multiple intracranial hemorrhages are rarely associated with cerebral amyloid angiopathy, venous sinus thrombosis, coagulopathy, oral anticoagulant therapy, vasculitis, hemorrhagic transformation of cerebral infarcts and in the presence of multiple intracranial pathologies such as vascular anomalies or tumors. [3] The incidence of multiple hypertensive hematomas has been reported to vary between 1 and 2.8% of spontaneous intracerebral hematomas. [1],[3],[4] In the reported cases with multiple intracranial hypertensive hemorrhages it appears that the duration of hypertension was relatively more, there was an increased incidence of previous strokes and there was a higher incidence of the presence of hypercholesterolemia. [2] The exact etiogenesis of hypertensive hemorrhage in multiple sites is unclear but could be related to generally known causes of hemorrhage. The sustained hypertension during a cerebral hemorrhage could trigger another bleeding owing to acute vascular changes in the penetrating arteries, affecting previously injured intima and media layers. [3] The outcome of most of the reported patients with hemorrhage at multiple sites has been poor. [2] The surgical treatment of these hematomas is determined by the location and size of the hematoma. Although the indication for surgery in cases with putaminal and thalamic hematomas remains controversial, most reviews have suggested an aggressive surgical approach in cases with cerebellar hemorrhage. [4],[5],[6],[7] The need for evacuation of the cerebellar clot in such a situation could be controversial. References
Copyright 2008 - Neurology India The following images related to this document are available:Photo images[ni08031f1.jpg] |
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