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175]

Case Report

Management of Simultaneously Occurring Multiple Massive

Intracerebral Hemorrhages
Luis Rafael Moscote‑Salazar1, Tariq Janjua2, Amit Agrawal3, Guru Dutta Satyarthee4, Willem Guillermo Calderon‑Miranda5

1
Cartagena Neurotrauma Occurrence of simultaneous multiple intracerebral hemorrhages  (ICHs) in different

Abstract
Research Group, University
of Cartagena, Cartagena,
arterial territories is an uncommon presentation. We report the cases of concurrent
Colombia; 2Regions Hospital, ocular and ICHs. The rarity of these lesions leads to delay in the diagnosis. Further
Saint Paul, Minnesota, USA; lack of clear management guidelines for these pathologies makes further delay in
3
MM Institute of Medical the institution of appropriate therapy. In addition, the pathogenesis, diagnosis, and
Sciences and Research, management along with pertinent literature are also reviewed.
Maharishi Markandeshwar
University, Ambala, Haryana,
4
All India Institute of Medical
Science, New Delhi, India;
5
National Autonomous
University of Mexico,
Mexico City, Mexico Keywords: Diagnosis, intracranial hemorrhage, intraorbital hemorrhage, management, prognosis

Introduction putamen, followed by the thalamus, the cerebellum, and

S pontaneous 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
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DOI:
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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
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
Address for correspondence: Dr. Luis Rafael Moscote‑Salazar,
Cartagena Neurotrauma Research Group, University of Cartagena
Cartagena, Colombia.
E‑mail: rafaelmoscote21@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com
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  Translat Crit Care
Med 2019;1:69-71.
Submission: 08-09-2018; Revision: 06-03-2019; Accepted: 18-03-2019

© 2019 Journal of Translational Critical Care Medicine | Published by Wolters Kluwer - Medknow 69
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Moscote‑Salazar, et al.: Management of simultaneously occurring multiple massive intracerebral hemorrhages
Figure 1: Computed tomography scan showing brainstem hemorrhage and
ocular right hemorrhage
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.
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.
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
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.[2‑5]
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.
70 Journal of Translational Critical Care Medicine  ¦  Volume 1  ¦  Issue 2  ¦  April-June 2019
Figure 2: Computed tomography scan showing the right basal ganglia and
left ocular left hemorrhage
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
Simultaneous ocular and ICH are infrequent. There are
no management guidelines for these pathologies. We
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Moscote‑Salazar, et al.: Management of simultaneously occurring multiple massive intracerebral hemorrhages

suggest that neurointensive management be a priority References

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
Nil.
Conflicts of interest
There are no conflicts of interest.
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