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 Table of Contents  
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 69-71

Management of Simultaneously Occurring Multiple Massive Intracerebral Hemorrhages

1 Cartagena Neurotrauma Research Group, University of Cartagena, Cartagena, Colombia
2 Regions Hospital, Saint Paul, Minnesota, USA
3 MM Institute of Medical Sciences and Research, Maharishi Markandeshwar University, Ambala, Haryana, India
4 All India Institute of Medical Science, New Delhi, India
5 National Autonomous University of Mexico, Mexico City, Mexico

Date of Submission08-Sep-2018
Date of Acceptance18-Mar-2019
Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Luis Rafael Moscote-Salazar
Cartagena Neurotrauma Research Group, University of Cartagena Cartagena
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jtccm.jtccm_14_18

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Occurrence of simultaneous multiple intracerebral hemorrhages (ICHs) in different arterial territories is an uncommon presentation. We report the cases of concurrent ocular and ICHs. The rarity of these lesions leads to delay in the diagnosis. Further lack of clear management guidelines for these pathologies makes further delay in the institution of appropriate therapy. In addition, the pathogenesis, diagnosis, and management along with pertinent literature are also reviewed.

Keywords: Diagnosis, intracranial hemorrhage, intraorbital hemorrhage, management, prognosis

How to cite this article:
Moscote-Salazar LR, Janjua T, Agrawal A, Satyarthee GD, Calderon-Miranda WG. Management of Simultaneously Occurring Multiple Massive Intracerebral Hemorrhages. J Transl Crit Care Med 2019;1:69-71

How to cite this URL:
Moscote-Salazar LR, Janjua T, Agrawal A, Satyarthee GD, Calderon-Miranda WG. Management of Simultaneously Occurring Multiple Massive Intracerebral Hemorrhages. J Transl Crit Care Med [serial online] 2019 [cited 2023 Mar 31];1:69-71. Available from: http://www.tccmjournal.com/text.asp?2019/1/2/69/268085

  Introduction Top

Spontaneous intracerebral hemorrhage (ICH) is associated with ocular hemorrhage in various pathophysiologic conditions such as essential arterial hypertension, tumors, vasculopathies, and coagulopathies among others. The cause of simultaneous ICH is infrequent; the presence of simultaneous cerebral and ocular hemorrhage has been very rarely described in the literature. The presence of vessel irregularities, such as strengthened jet flow, can occur in vulnerable penetrating arteries and could cause a subsequent ICH. Rupture of bilateral microaneurysms on lenticulostriate or thalamoperforator arteries may be the cause of parenchymal vessel distortion coupled with reflex increase in the blood pressure.

An alteration of cerebral autoregulation occurs and conditions the presentation of bleeds in multiple places, including at the ocular level.

ICH accounts for 8%–14% of strokes occurring during the first attack, and simultaneous hemorrhage is an uncommon event. Multiple ICHs have been observed in only 2% of hemorrhagic strokes.[1]

Spontaneous single ICH occurs predominantly in a deep location of the brain, the most common of which is the putamen, followed by the thalamus, the cerebellum, and the subcortical white matter. However, in simultaneous multiple bleeds, it was most commonly detected in the bilateral thalami and then the putamen. Infratentorial hemorrhage was rare. Although the multiple bleeds were in different hemisphere, they were usually related to the same circulation system. Thalamoperforator arteries are responsible for thalamic hemorrhage while putaminal hemorrhages originate from lenticulostriate arteries which are from the middle cerebral artery or proximal anterior cerebral artery in the anterior circulation.

  Case Reports Top

Case 1

A 60-year-old female was brought with the loss of consciousness for 6 h. The family denied any head trauma, seizures, and illicit drug ingestion. There was no family history of note. Computed tomography (CT) revealed the presence of brainstem hemorrhage [Figure 1] with massive right ocular hemorrhage. The conservative management was used in intensive care. She was known hypertensive on presentation with unknown antihypertensive medications as outpatient medication. However, she succumbed in 36 h after admission to the hospital.
Figure 1: Computed tomography scan showing brainstem hemorrhage and ocular right hemorrhage

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Case 2

A hypertensive 56-year-old male patient presented with a history of 24 h of severe sudden headache and left-sided hemiplegia. There was no family history of note. CT scan revealed the presence of the right thalamic and left ocular hemorrhage [Figure 2]. He was admitted for conservative management.
Figure 2: Computed tomography scan showing the right basal ganglia and left ocular left hemorrhage

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He was managed conservatively with neurocritical care support. He responded well with minimal deficit and discharged from hospital after 2 weeks. The patient was scheduled on a regular physiotherapy program and follow-up visits. He was followed up in the outpatient setting ophthalmology and clinical neurology appointments.

  Discussion Top

The occurrence of multiple intracranial site hemorrhage is extremely uncommon. The exact underlying pathology is still not known. Reported causative factors include hypertension, multiple microbleeds, cerebral amyloid angiopathy, vasculitis, administration of intravenous tissue plasminogen activator, asphyxiation, deep cerebral vein thrombosis, and neoplasm; these causative factors are like those for single spontaneous ICH.[2],[3],[4],[5]

Exact mechanism is unknown. Komiyama et al. demonstrated the presence of simultaneous hemorrhages from multiple lenticulostriate arteries in a man suffering from chronic hypertension with the development of multiple intracranial hemorrhages.[6]

Acute ICH might be causing acute hemodynamic changes of intracranial vessels which affect perforating vessels at different locations causing rupture and development of multiple site bleeds.

Angiography of intracranial vessels may show the presence of irregularities of the vessel wall, including strengthened jet flow, which aggravate vulnerability of penetrating and perforating arteries causing multiple site hemorrhage. Other angiography finding may include multiple vascular stenosis and microangiopathic changes, these may attribute to greater vascular fragility and disproportionately increased risk of future hemorrhage.[7]

Clinical features of multiple intracranial and orbital bleed are related to site of the presence of hematoma and depends the site, side, volume, the presence of mass effect, associated hydrocephalus, and preexisting cortical atrophy.

A common risk factor in these cases is the presence of arterial hypertension. It has been established by angiography that vascular irregularities, including multiple focal stenosis and calcified plaques that may be at risk for the development of this pathology.

Further investigations are needed to ascertain the exact etiology and management of this condition. The diagnosis requires detailed clinical history, assessment of hypertension, obesity, diabetes, intake of antiplatelet, or anticoagulant agent with detailed neurological evaluation. CT shows the presence of multiple site hemorrhage, delineates site, size, mass effect, volume, associated edema, mass effect, and hydrocephalus. Magnetic resonance imaging may help in better delineation, and angiography may be helpful in detecting vascular pathology, including vascular malformation, irregularities in the vessel wall, the presence of calcified atheromatous plaques, and the presence of multiple focal arterial stenosis.

Massive ocular hemorrhage requires evaluation and follow-up by ophthalmology.

  Conclusions Top

Simultaneous ocular and ICH are infrequent. There are no management guidelines for these pathologies. We suggest that neurointensive management be a priority in this pathology. The evaluation by ophthalmology is complementary to determine the ocular commitment and the subsequent follow-up of the patient. The mechanism of strengthened jet flow may be associated with the genesis of this entity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have give their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Seijo M, Ucles A, Gil-Nagel A, Balseiro J, Calandre L. Multiple cerebral hematomas: Review of 7 cases. Rev Neurol 1996;24:549-53.  Back to cited text no. 1
Sorimachi T, Ito Y, Morita K, Fujii Y. Microbleeds on gradient-echo T2(*)-weighted MR images from patients with multiple simultaneous intracerebral haemorrhages. Acta Neurochir (Wien) 2007;149:171-6.  Back to cited text no. 2
Kase CS, Pessin MS, Zivin JA, del Zoppo GJ, Furlan AJ, Buckley JW, et al. Intracranial hemorrhage after coronary thrombolysis with tissue plasminogen activator. Am J Med 1992;92:384-90.  Back to cited text no. 3
Mühlau M, Schlegel J, Von Einsiedel HG, Conrad B, Sander D. Multiple progressive intracerebral hemorrhages due to an angiosarcoma: A case report. Eur J Neurol 2003;10:741-2.  Back to cited text no. 4
Chanda A, Nanda A. Multiple cavernomas of brain presenting with simultaneous hemorrhage in two lesions: A case report. Surg Neurol 2002;57:340-4.  Back to cited text no. 5
Komiyama M, Yasui T, Tamura K, Nagata Y, Fu Y, Yagura H. Simultaneous bleeding from multiple lenticulostriate arteries in hypertensive intracerebral haemorrhage. Neuroradiology 1995;37:129-30.  Back to cited text no. 6
Yen CP, Lin CL, Kwan AL, Lieu AS, Hwang SL, Lin CN, et al. Simultaneous multiple hypertensive intracerebral haemorrhages. Acta Neurochir (Wien) 2005;147:393-9.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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