Multiple spontaneous simultaneous intracerebral hemorrhages

Abstract

Simultaneous occurrence of intracerebral hemorrhage (ICH) in different arterial territories is an uncommon event. We report on two cases of multiple spontaneous simultaneous ICH for which we could find no specific cause. A 73-year-old man, with no related medical history, was admitted to the hospital with simultaneous bithalamic ICH, and subsequently died of recurrent pneumonia. Second patient was a 60-year-old man who presented with simultaneous ICH in the pons and thalamus; he died of recurrent bleeding. We review the possible pathological mechanisms, clinical and radiologic features of simultaneous multiple ICH.

Keywords: Hypertension; Intracerebral hemorrhage; Multiple; Simultaneous.

Fig. 1

A 73-year-old male patient (case 1) with spontaneous, simultaneous bithalamic hemorrhage. Brain computed tomography shows bilateral thalamic hemorrhage with intraventricular hemorrhage in the lateral ventricles.

Fig. 2

T2-weighted brain magnetic resonance imaging of case 1. Microangiopathic changes in the periventricular area with early subacute bithalamic hemorrhage are noted.

Fig. 3

Transfemoral carotid angiography (case 1) was performed at the hospital 24 days after admission. (A) Multiple focal vascular stenosis in the anterior cerebral artery and middle cerebral artery. (B) Mild atheroma is shown in the left cervical carotid bifurcation. (C) Focal stenosis is shown in the right vertebral artery.

Fig. 4

A 60-year-old male patient (case 2) with spontaneous, simultaneous intracerebral hemorrhage. (A) Brain computed tomography shows intracerebral hemorrhage in the pons. (B) Acute right thalamus hemorrhage is noted. The two hemorrhages were completely separated spatially.

Fig. 5

Follow-up computed tomography of case 2 after neurologic deterioration into a coma. (A) An increased amount of intracerebral hemorrhage in the pons is compressing the fourth ventricle. (B) There is no significant change in the hemorrhage in the right thalamus.

Fig. 6

Initial computed tomography angiography of case 2. (A) Diffuse calcified plaques in the bilateral distal internal carotid arteries are noted. (B) Focal stenosis in the right posterior cerebral artery, P2 portion, is shown.