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Bilateral basal ganglia hemorrhage: a systematic review of etiologies,

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DOI: 10.1007/s10143-023-02044-x

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Neurosurgical Review (2023) 46:135
https://doi.org/10.1007/s10143-023-02044-x

REVIEW

Bilateral basal ganglia hemorrhage: a systematic review of etiologies,

management strategies, and clinical outcomes
Gina Watanabe1 · Andie Conching1 · Christian Ogasawara2 · Vishal Chavda3 · Othman Bin‑Alamer4 · Ali S. Haider5 ·
Stefano M. Priola6 · Mayur Sharma7 · Samer S. Hoz8 · Bipin Chaurasia9 · Giuseppe E. Umana10 · Paolo Palmisciano8

Received: 25 January 2023 / Revised: 6 May 2023 / Accepted: 27 May 2023

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Bilateral basal ganglia hemorrhages (BBGHs) represent rare accidents, with no clear standard of care currently defined. We
reviewed the literature on BBGHs and analyzed the available conservative and surgical strategies. PubMed, Scopus, Web of
Science, and Cochrane were searched following the PRISMA guidelines to include studies reporting patients with BBGHs.
Clinical characteristics, management, and outcomes were analyzed. We included 64 studies comprising 75 patients, 25 (33%)
traumatic and 50 (67%) non-traumatic. Traumatic cases affected younger patients (mean age 35 vs. 46 years, p=0.014) and
males (84% vs. 71%, p=0.27) and were characterized by higher proportion of normal blood pressures at admission (66% vs.
13%, p=0.0016) compared to non-traumatic cases. Most patients were comatose at admission (56%), with a mean Glasgow
Coma Scale (GCS) score of 7 and a higher proportion of comatose patients in the traumatic than in the non-traumatic group
(64% vs. 52%, p=0.28). Among the traumatic group, motor vehicle accidents and falls accounted for 79% of cases. In the
non-traumatic group, hemorrhage was most associated with hypertensive or ischemic (54%) and chemical (28%) etiologies.
Management was predominantly conservative (83%). Outcomes were poor in 56% of patients with mean follow-up of 8
months. Good recovery was significantly higher in the traumatic than in the non-traumatic group (48% vs. 17%, p=0.019).
BBGHs are rare occurrences with dismal prognoses. Standard management follows that of current intracerebral hemorrhage
guidelines with supportive care and early blood pressure management. Minimally invasive surgery is promising, though
substantial evidence is required to outweigh the potentially increased risks of bilateral hematoma evacuation.

Keywords  Basal ganglia · Head trauma · Hematoma evacuation · Intracerebral hemorrhage · Neurointensive care
management

Giuseppe E. Umana and Paolo Palmisciano contributed equally and

share the senior authorship.

6
* Paolo Palmisciano Department of Neurosurgery, Health Sciences North,
paolo.palmisciano94@gmail.com Northern Ontario School of Medicine, Sudbury, Ontario,
Canada
1
John A. Burns School of Medicine, University of Hawai’i, 7
Department of Neurosurgery, University of Minnesota,
Honolulu, HI, USA
Minneapolis, MN, USA
2
Department of Neurosurgery, University of Texas Medical 8
Department of Neurosurgery, University of Cincinnati, 231
Branch, Galveston, TX, USA
Albert Sabin Way, Cincinnati, OH 45229, USA
3
Department of Pathology, Stanford of School of Medicine, 9
Department of Neurosurgery, Neurosurgery Clinic, Birgunj,
Stanford University Medical Centre, Stanford, Palo Alto, CA,
Nepal
USA
10
4 Department of Neurosurgery, Trauma Center, Gamma Knife
Department of Neurosurgery, University of Pittsburgh
Center, Cannizzaro Hospital, Catania, Italy
Medical Center, Pittsburg, PA, USA
5
Department of Neurosurgery, The University of Texas
M.D. Anderson Cancer Center, Houston, TX, USA

13
Vol.:(0123456789)

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

 135   Page 2 of 24
Introduction
Intracerebral hemorrhage (ICH) is the second most com-
mon cause of stroke, accounting for 10–15% of worldwide
cases and leading to major morbidity and mortality [1, 2].
Basal ganglia (BG) hemorrhages represent singular entities,
mostly occurring in spontaneous ICH and less frequently in
traumatic ICH [3, 4]. Bilateral basal ganglia hemorrhages
(BBGHs) are extremely rare and poorly studied. In view
of the BG’s deep location and highly metabolic nature,
BBGHs may arise from coup-contrecoup contusions after
closed-head injury, hypertensive crises, cerebral venous
thrombosis, viral infections, or chemical poisoning [5–9].
Clinical presentation is severe and prognosis dismal, charac-
terized by early neurological deterioration from hematoma
expansion and corticospinal tract compression, secondary
injury from perihematomal brain swelling with intracranial
hypertension, and late hemotoxicity from blood degradation
products [10, 11].
Several trials investigated and compared the role of con-
servative medical care, open surgical hematoma evacua-
tion, minimally invasive/endoscopic hematoma aspiration,
and thrombolysis in the treatment of traumatic and non-
traumatic ICHs [12–15]. Although surgical intervention
was generally not associated with significant improve-
ments in outcome over standard conservative therapies,
evidence suggests benefit for certain subgroups, particu-
larly those with larger hemorrhage volumes and higher
baseline Glasgow Coma Scale (GCS) scores [16, 17].
Endoscopic and minimally invasive surgical approaches
appear to be more favorable in patients with deep-seated
hematomas involving the BG and the thalami [18, 19].
Still, the surgical-related risks should be considered, with
a particular focus on complex cases such as BBGHs.
Although operative and non-operative management strat-
egies have been widely studied for unilateral BG ICHs, only
few reports on BBGHs are currently available, heterogene-
ous in clinical characteristics and treatments. In this system-
atic review, we comprehensively summarized demograph-
ics, etiologies, clinical features, and management strategies
of BBGHs, further analyzing the impact of current treat-
ments on patient functional outcomes and survival.
Methods
Literature search
A systematic review was conducted following the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [20]. PubMed, Scopus,
13
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Neurosurgical Review (2023) 46:135
Web of Science, and Cochrane were searched from data-
base inception to March 27, 2022, using the combination
of the Boolean operators “OR” and “AND” and the follow-
ing search terms: “bilateral,” “basal ganglia,” and “hemor-
rhage.” Studies were uploaded to Mendeley, and duplicates
were removed.
Study selection
A priori inclusion and exclusion criteria were defined. Studies
were included if they (1) included patients with radiologically
confirmed intracranial hematomas/hemorrhages involving the
bilateral BG; (2) reported available data on clinical features,
treatment strategies, and post-treatment outcomes; and (3) were
written in English. Studies were excluded if they were (1) litera-
ture reviews, autopsy reports, or animal studies; (2) studies with
unclear distinction between patients with BBGH and patients
with other types of intracranial hemorrhages; and (3) studies
lacking 2 or more of patients’ demographics, clinical presenta-
tion, management strategies, or post-treatment outcomes.
Two independent reviewers (G.W. and P.P.) screened
titles and abstracts of all retrieved studies, and then assessed
full texts of articles that met inclusion criteria. Disagree-
ments were solved by a third reviewer (G.E.U.). Eligible
studies were included based on the predefined criteria, and
references were screened for additional relevant articles.
Data extraction
Data were extracted by two authors (A.C. and C.O.), and then
confirmed independently by one additional author (G.W.).
Missing data were either not reported or not differentiable from
other non-relevant data. Extracted data included authors, year,
age, gender, etiology, past medical history, level of conscious-
ness, location of hemorrhage, dominant hemisphere, presence
of concurrent intracranial hemorrhage, blood pressure, glucose
level, GCS at admission and discharge, radiological exam and
findings, hemorrhage volume, management type and details,
complications, follow-up duration, overall survival, prognosis,
and vital status. The prognosis was categorized based on the
descriptions provided in the texts using the Glasgow Outcome
Scale (GOS). Good recovery was defined as lack of symptoms
or minor deficits not affecting activities of daily living (e.g.,
“No focal neurological deficits,” “GCS 15,” “Able to work as
before”). Moderate disability was defined as having some dis-
ability interfering with the ability to resume work, school, or
other previous activities, but the individual remains independ-
ent (e.g., “Deaf,” “Some motor weakness”). Severe disability
was defined as needing partial or full assistance of activities of
daily living (e.g., “Hemiparesis,” “Bilateral optic atrophy”). A
vegetative state was defined as an absence of awareness of self
and the environment (e.g., “Comatose”). Based on etiologies,
BBGHs were divided into traumatic and non-traumatic groups.
Neurosurgical Review (2023) 46:135 Page 3 of 24  135
Data synthesis and quality assessment
Primary outcomes of interest were patient demographics (age,
gender, past medical history), clinical characteristics (signs
and symptoms, vitals, labs, GCS), hemorrhage characteristics
(postulated etiology, location, concurrent hemorrhage, hemor-
rhage volume), management (conservative vs. surgical), and
outcomes (length of stay, follow-up, improvement in symp-
toms, clinical status, overall survival, prognosis). The level of
evidence of each article was evaluated upon the 2011 Oxford
Centre For Evidence-Based Medicine guidelines [21]. Meta-
analysis was precluded because all included studies were level
IV or V of evidence, and hazard ratios could not be deducted.
The risk of bias of each article was independently assessed by
two authors (A.C. and G.W.) using the Joanna Briggs Institute
checklists for case series [22].
Statistical analysis
Descriptive analyses were performed using SPSS V.25 (IBM
Corp, Armonk, NY). Continuous variables are summarized
as means with standard deviation and range. Categorical
variables were reported as frequencies and percentages.
Comparisons between the traumatic and non-traumatic
groups were conducted using chi-square tests for categorical
variables or Fisher’s exact test for categories with less than
five observations, and t-test for continuous variables only for
the features reliably and consistently reported among each
category type.
Results
Study selection
Figure 1 illustrates the study selection process. The initial
search yielded 684 citations (PubMed: 197; Scopus: 321;
Web of Science: 155; Cochrane: 11), of which 64 studies
were finally included upon the pre-determined criteria: 4
case series (involving 9 patients) and 60 case reports (involv-
ing 66 patients), categorized as level IV and V of evidence,
respectively (Table 1). Quality assessment resulted in low
risk of bias for all included studies (Supplementary File 1).
Demographics and clinical characteristics
There were 75 patients with BBGHs that met our inclusion
criteria, 25 (33%) traumatic and 50 (67%) non-traumatic
hemorrhages (Table 2). Patients were mostly male (76%)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
with a mean age of 42 years (range 0.006–89 years). When
grouped by traumatic versus non-traumatic hemorrhage,
cases of hemorrhage associated with trauma had a sig-
nificantly younger mean age (35 vs. 46 years, p=0.014), a
higher proportion of males (84% vs. 71%, p=0.27), and a
significantly higher proportion of unremarkable past medi-
cal history (88% vs. 37%, p=0.0016). A minority of patients
(9%) were on anticoagulant or antiplatelet medications or
were reported to have coagulation factor deficiencies. The
most common comorbidities were hypertension (41%) or
diabetes (16%). Clinical characteristics are reported in
Table 3. Overall, the most common presentation involved
motor symptoms (26%), such as weakness, and headaches
(11%). Among the 14 cases that described the laterality of
weakness, most patients experienced unilateral weakness
(79%), with a nearly equal distribution of right- (47%) and
left-sided hemiplegia or hemiparesis. The non-traumatic
group had a slightly higher proportion of constitutional and
neurologic abnormalities though this was not statistically
significant. Blood pressure at admission was within normal
limits in 36% of patients, with a significantly higher pro-
portion of normal readings reflected in the traumatic versus
non-traumatic group (66% vs. 13%, p=0.0016). Most of the
reported glucose levels were within normal limits (70–110
mg/dL) (64%), with a higher proportion of normal glucose
levels in the traumatic versus non-traumatic group (77% vs.
50%, p=0.16). Most patients were comatose at admission
(56%), with a mean GCS of 7. The traumatic group had a
significantly higher GCS mean at admission when compared
to the non-traumatic group (8 vs. 6, p = 0.046). A higher
proportion of patients in the traumatic group were comatose
at admission (64% vs. 52%, p = 0.28).
BBGHs were mostly associated with hypertension
(21%), motor vehicle accidents (20%), and methanol tox-
icity (10%) (Table 4). Among the traumatic group, motor
vehicle accidents and falls accounted for 79% of cases. In the
non-traumatic group, hemorrhage was most associated with
vascular or ischemic (55%) and chemical (28%) etiologies.
The putamen was the most denoted location (39%), followed
by BG not otherwise specified (37%) and globus pallidus
(20%). When analyzing by traumatic versus non-traumatic
hemorrhage groups, traumatic cases had a higher propor-
tion of globus pallidus locations (37% vs. 16%, p=0.073)
and a lower proportion of BG not otherwise specified (16%
vs. 38%, p=0.098). Most articles referred to the BBGH
lesions as ICH (76%), while others referred to them as hem-
orrhagic infarction (21%) or hemorrhagic necrosis (3%).
Concurrent intracranial hemorrhage (e.g., subarachnoid,
epidural, or subdural hemorrhage) was present in a minority
of cases overall (24%), with a significantly higher presence
in the traumatic versus non-traumatic group (44% vs. 13%,
p=0.0074). In the 10 cases that reported hemorrhage vol-
ume, there was an average estimate of 22 mL on each side.
13
 135   Page 4 of 24 Neurosurgical Review (2023) 46:135

Fig. 1  PRISMA 2020 flow

diagram Identification of new studies via databases

Records identified from:

Records removed before
PubMED (n = 197) screening:
Scopus (n = 321)
Web of Science (n = 155) Duplicate records (n = 274)
Cochrane (n = 11)

Records screened Records excluded

(n = 410) (n = 314)

Reports sought for Records not retrieved

retrieval (n = 96) (n = 0)

Full text assessed for

eligibility Records excluded (n = 32):
(n = 96)
No bilateral basal ganglia
hemorrhage (n = 15)

No hemorrhage (n = 10)

Autopsy (n = 7)
New studies included in
review
(n = 64)

A larger average combined hematoma volume was observed
for the non-traumatic group than for the traumatic group, but
this was not statistically significant (27 vs. 15 mL, p=0.18).
Management and outcomes
Management strategies are reported in Table 5. Patients were
mostly managed conservatively (83%). Among studies that
reported medical treatment, mannitol (26%) and pheny-
toin (for seizure prophylaxis) (19%) were the most often
employed agents in traumatic cases. Meanwhile, unspeci-
fied hypertensive agents (12%) and heparin (for deep venous
thrombosis prophylaxis) (10%) were most often used in
non-traumatic cases. A higher proportion of medications
involved antiepileptics in the traumatic group compared to
the non-traumatic group (26% vs. 6%, p=0.081), all of which
were used prophylactically without mention of seizures dur-
ing admission nor history of seizures. In the eleven studies
that reported surgical treatment, hematoma evacuation or
drainage (including external ventricular drainage) was the
predominant procedure overall (55%), followed by decom-
pressive craniectomy (27%), third ventriculostomy (9%), and
intracranial pressure (ICP) monitor placement (9%). The
most frequently performed surgical procedure was hema-
toma evacuation in the non-traumatic group (67%) compared
to decompressive craniectomy in the traumatic group (40%).
Among cases of surgical intervention, none reported
which hemisphere was dominant nor mentioned considera-
tion of cerebral dominance. Of cases with explicitly reported
coagulopathic status (n = 6), none was on anticoagulant or
antiplatelet medications nor had any known bleeding disor-
der. There were also no reports of chronic kidney disease
or other renal abnormalities in this surgical subgroup, and
no mention of postcritical management. One case referred
to the lesion as a hemorrhagic infarction. In all cases of
BG hematoma evacuation reporting details of the procedure
(n = 3), drainage was performed bilaterally. Hemorrhage
volume was slightly asymmetric with an average of 10 mL

13

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 Table 1  Overview of all included studies
No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)
LOE

Traumatic
Neurosurgical Review

1 Nagano Case report M 3 Penetrat- - - - Surgical - - - - - - A

et al. – –V ing head
1980 [23] injury
2 Lodder & Case report F 75 - - DS - Conserva- - Yes - - Arm Moderate A
Baard – –V tive rigidity, disability
1981 [24] decreased
(2023) 46:135

facial
expression
3 Ozgun & Case report M 32 Lightning 140/90 LN - Conserva- 5 Yes - 8 Deaf Moderate A
Castillo – –V strike tive disability
1995 [25]
4 Jang et al. – Case report M 50 Fall WNL - 15 Conserva- 14 - - 0.47 No FND Good A
2007 [26] –V tive recovery
5 Ishihara Case report M 0.92 Fall WNL CS - Conserva- 9 Yes - 25 No FND Good A
et al. – –V tive recovery
2009 [27]
6 Kaushal Case report M 42 MVA 136/88 LN, EC 5 Conserva- 14 Yes 15 - Some motor Moderate A
et al. – –V tive weakness disability
2011 [28]
7 Aygun et al. Case report M 35 Blast injury WNL - - Conserva- 7 Yes 15 - No FND Good A
– 2012 –V tive recovery
[29]
8 Bhargava Case report M 25 MVA WNL BG 4 Conserva- 35 Yes - - Dysphasia, Severe dis- A
et al. – –V tive R spastic ability
2012 [30] hemipa-
resis
Case report M 50 MVA WNL BG 4 Conserva- - Yes - - Motor - A
–V tive improve-
ment
9 Jain et al. – Case report M 38 Fall WNL - 15 Conserva- 5 - 15 2 No FND Good A
2013 [31] –V tive recovery
10 Calderon- Case report M 28 MVA WNL - 6 Conserva- 7 No - 0.1 Dead - D
Miranda –V tive

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

et al. –
2014 [32]
11 Pandey et al. Case report M 37 MVA WNL CG 6 Surgical 28 No 6 - Coma Vegetative A
Page 5 of 24 

– 2014 –V state
[33]
135

13
 Table 1  (continued)
135  

No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)

13
LOE

12 Vega et al. – Case report M 57 Assault - LN 8 Conserva- 17 Yes 15 18 Memory Severe dis- A
Page 6 of 24

2015 [34] –V tive deficits, ability

temporal
disorienta-
tion, dys-
calculia
13 Baek et al. – Case report M 6 MVA - - 6 Surgical 39 No - - Vegetative Vegetative A
2016 [35] –V state state
14 Bathla et al. Case report M 16 MVA WNL - 4 Surgical 6 No - 0.2 Dead - D
– 2016 [5] –V
Case report M 22 MVA - LN 3 Surgical 6 No - 0.2 Dead - D
–V
15 Kankane Case report M 20 MVA WNL BG 9 Conserva- 3 Yes 15 3 No FND Good A
et al. – –V tive recovery
2016 [36] Case report M 45 MVA WNL CG 10 Conserva- 5 Yes 15 3 No FND Good A
–V tive recovery
16 Zhang et al. Case report F 45 Fall 160/100 - 8 Conserva- 29 Yes 15 1 L hemipa- Severe dis- A
– 2016 [9] –V tive resis ability
17 Reddy et al. Case report M 34 MVA WNL - 5 Conserva- - No - 0.1 Dead - D
– 2019 –V tive
[37] Case report M 40 MVA - - 7 Conserva- - Yes 14 - - Good A
–V tive recovery
Case report F 40 Fall - - 10 Conserva- 20 Yes 15 - - Good A
–V tive recovery
18 Lee et al. – Case report M 33 Assault 100/60 GP 15 Conserva- 28 - 15 7 No FND Good A
2020 [38] –V tive recovery
19 Mughis Case report M 30 MVA 230/118 - 12 Conserva- 5 Yes 15 - No FND Good A
et al. – –V tive recovery
2020 [39]
20 Anh et al. – Case report F 63 MVA 150/90 LN 9 Conserva- 31 Yes 15 2 Initial Good A
2022 [40] –V tive quadriple- recovery
Neurosurgical Review

gia and
aphasia,

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

normal
strength
and
speech
(2023) 46:135

recovered
2 mo later
 Table 1  (continued)
No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)
LOE

Non-traumatic
Neurosurgical Review

21 Finelli et al. Case report M 57 - 104/60 GP - Conserva- - Yes - - Quadriple- Severe dis- A
– 1984 –V tive gic, mute ability
[41]
22 Naheedy Case report F 30 Preeclamp- - BG - - - - - - - - A
et al. – –V sia
1985 [42]
(2023) 46:135

23 Sato et al. – Case report M 45 Anticoagu- - P - Conserva- 30 Yes - 1 Walking Severe dis- A
1986 [43] –V lants tive with cane, ability
motor
dysphasia,
dysphagia,
dysarthria,
L hemipa-
resis
24 Erbguth Case series F 48 VT - BG - Conserva- 73.5 Yes - - Choreatic Moderate A
et al. – – IV tive movement disability
1991 [44] of R hand
25 Fujioka Case report M 69 CA - CS - - 40 No - 1.33 Vegetative Vegetative A
et al. – –V state state
1994 [45]
26 Kabuto et al. Case report M 65 HTN - P, ventri- - Conserva- - No - 0.13 Dead - D
– 1995 –V cles, IC tive
[46]
27 Nagatomo Case report F 50 VT - BG - Conserva- 21 Yes 4 0.7 No FND Good A
et al. – –V tive recovery
1995 [8]
28 Wang & Case report M 40 VT - BG - Conserva- 20 - - 1 No FND Good A
Shen – –V tive recovery
1995 [47]

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Page 7 of 24 
135

13
 Table 1  (continued)
135  

No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)

13
LOE

29 Ertl-Wagner Case report F 59 DKA - BG - Conserva- 7 Yes - - Paraparesis, Moderate A

Page 8 of 24

– 1999 –V tive bilateral disability

[48] facial
palsy,
dysdia-
dochoki-
nesis,
impaired
coordina-
tion and
fine motor
function
30 Pidcock Case report F 8 - 140/100 P - Conserva- 30 Yes 6 - Decreased Severe dis- A
et al. – –V tive drooling, ability
1999 [49] improved
language
produc-
tion, use
of com-
munica-
tion board
31 Raabe & Case report M 46 HTN, HA 135/75 BG - Conserva- - Yes - - Severely Severe dis- A
Krug – –V tive disabled ability
1999 [50]
32 Kohshi et al. Case report F 76 HTN 196/90 Thal, P, IC - Conserva- 28 Yes - - Slight hemi- Moderate A
– 2000 –V tive paresis disability
[51]
33 Cho et al. – Case report M 40 HHS - P - Conserva- - No - 24 Vegetative Vegetative A
2002 [52] –V tive state state
34 Silliman Case report M 35 HTN 180/104 P - Conserva- 10 No - - Dead - D
et al. – –V tive
2003 [53]
35 Caparros- Case report M 50 EG - GP - Conserva- 30 Yes 14 6 No FND Good A
Neurosurgical Review

Lefebvre –V tive recovery

et al. –

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

2005 [54]
36 Sarkar et al. Case report M 40 JE 180/90 BG - Conserva- - Yes - 2 Mild Good A
– 2005 –V tive emotional recovery
(2023) 46:135

[55] lability
 Table 1  (continued)
No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)
LOE

37 Yen et al. – Case series M 55 HTN - P 3 Conserva- - - - - - - -

Neurosurgical Review

2005 [56] – IV tive

M 64 HTN - P 6 Surgical - No - - Dead - D
M 49 HTN - P 3 Conserva- - - - - - - -
tive
38 Ari et al. – Case report M 25 Methanol 130/90 P - Conserva- - Yes - 2 Bilateral Severe dis- A
(2023) 46:135

2007 [57] –V tive optic ability

atrophy
39 Asimi et al. Case report M 65 HTN 190/110 P 11 Conserva- 1 - - 0.03 Dead - D
– 2007 –V tive
[58]
40 Sefidbakht Case series M 27 Methanol - LN - Conserva- - - - - - - A
et al. – – IV tive
2007 [59] M 26 Methanol - LN - Conserva- - - - - - - A
tive
41 Nishina Case report F 74 HTN 220/90 P 4 Conserva- - No - 0.2 Dead - D
et al. – –V tive
2010 [60]
42 Terzi et al. – Case report M 63 HTN 190/110 BG - Conserva- - - - - No FND Good A
2010 [61] –V tive recovery
43 Amin et al. Case report F 28 Stroke 140/70 LN 3 Conserva- 35 Yes - 2 Dysphagia, Severe dis- A
– 2011 –V tive moderate ability
[62] hypoki-
nesia,
rigidity
44 Takeuchi Case series M 57 HTN 183/120 P 7 Surgical - - - - Severely Severe dis- A
et al. – – IV disabled ability
2011 [63] M 59 HTN 198/140 P 3 Surgical - No - - Vegetative Vegetative A
state state
M 89 HTN 150/78 P 3 Conserva- - No - - Dead - D
tive
45 Westover & Case report F 58 SSRI, - BG - Conserva- 30 Yes - 1 Minimal Good A

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Cohen. – –V RCVS tive receptive recovery
2011 [64] aphasia
46 Cha et al. – Case report M 55 CA 69/43 BG 3 Conserva- 15 No - 0.5 Dead - D
2012 [65] –V tive
Page 9 of 24 
135

13
 Table 1  (continued)
135  

No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)

13
LOE

47 Permpalung Case report M 56 Methanol - BG - Conserva- - Yes - - - - A

et al. – –V tive
Page 10 of 24

2013 [66]
48 Srivastava & Case report M 35 Methanol - P - Conserva- - Yes - - - - A
Kadam – –V tive
2013 [67]
49 Thiruna- Case report M 30 Methanol - BG 8 Conserva- - Yes - - - - A
vukkarasu –V tive
et al. –
2013 [68]
50 Heck et al. – Case report M 29 Aneurysm - BG - Conserva- 11 - - 18 Minor Moderate A
2014 [69] –V tive speech disability
difficul-
ties, could
not use R
hand for
precise
manipula-
tions
51 Baldawa Case report M 60 HTN 220/110 BG - Conserva- 30 No - - Vegetative Vegetative A
et al. – –V tive state state
2015 [70]
52 Lee et al. – Case report M 32 Methanol - BG 3 Conserva- 21 - - 0.75 Dead - D
2015 [7] –V tive
53 Mahale et al. Case report M 5 JE 98/72 BG - Conserva- - Yes - - Akinetic- Severe dis- A
– 2015 –V tive mute state ability
[71]
54 Zhao et al. – Case report M 57 HTN 192/102 BG 5 Surgical - Yes - 10 Motor Moderate A
2016 [72] –V weakness disability
55 Boukobza Case report F 54 CA - CS 3 Conserva- 6 No - - Dead - D
& Baud – –V tive
2017 [73] Case report M 64 CA - CS 3 Conserva- 7 No - - Dead - A
Neurosurgical Review

–V tive
56 Gupta et al. Case report - 0.0055 GBS menin- - CS - Surgical - - - 6 Develop- Severe dis- A

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

– 2018 –V gitis mental ability
[74] delay,
cerebral
palsy,
(2023) 46:135

hypsar-
rhythmia
 Table 1  (continued)
No. Authors - Study Sex Age Etiology* BP Locations GCS1 Manage- LOS (days) Improved? GCS2 OS** Outcomes Prognosis Status
Year design – ment (mon)
LOE

57 Mahavar Case report M 25 Toluene 120/80 BG 3 Conserva- - No - - Dead - D

Neurosurgical Review

et al. – –V tive
2018 [75]
58 Daci et al. – Case report F 60 COVID WNL BG - - 11 - - 0.36 Dead - D
2020 [6] –V
59 Guo et al. – Case report M 0.083 Methyl- - C - Conserva- 14 - 14 - No FND - A
2020 [76] –V malonic tive
(2023) 46:135

acidemia
60 Haddadi Case report F 54 COVID 150/100 BG 10 Conserva- 7 Yes 5 - No FND Good A
et al. – –V tive recovery
2020 [77]
61 Schweyer Case report F 51 Olanzapine WNL BG - Surgical - Yes - 2 Vegetative Vegetative A
et al. – –V state state
2020 [78]
62 Shaheed Case report M 62 - WNL LN 14 Conserva- - - - - - - A
et al. – –V tive
2020 [79]
63 Zhang et al. Case report F 52 HTN 180/100 BG 6 Surgical - Yes 2 24 Mild motor Moderate A
– 2020 –V disorder, disability
[80] speech did
not return
to normal
64 Kayastha Case report M 39 - 200/100 BG 12 Conserva- 9 Yes - - No FND Moderate A
et al. – –V tive disability
2022 [81]

Abbreviations: BG, basal ganglia; CA, cardiac arrest; CG, capsuloganglionic; CS, corpus striatum; DKA, diabetic ketoacidosis; DS, dorsal striatum; FND, focal neurological deficits; EC, exter-
nal capsule; EG, ethylene glycol; GBS, group B Streptococcus; GCS, Glasgow Coma Scale; GCS1, admission GCS; GCS2, discharge or last known GCS; GP, globus pallidus; HA, headache;
HHS, hyperglycemic hyperosmolar syndrome; HTN, hypertension; IC, internal capsule; JE, Japanese encephalitis; LOE, level of evidence; LOS, length of stay; LN, lentiform nuclei; MVA, motor
vehicle accident; OS, overall survival; P, putamen; RCVS, reversible cerebral vasoconstriction syndrome; SSRI, selective serotonin reuptake inhibitor; Thal, thalamus; Tx, treatment; VT, venous
thrombosis; WNL, within normal limits
*Postulated etiology
**If patient alive, this refers to months of follow-up

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Page 11 of 24 
135

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 135   Page 12 of 24 Neurosurgical Review (2023) 46:135

Table 2  Summary of patient Characteristics Overall Non-traumatic Traumatic p-value

demographics. The number
of patients for which values Cohort size 75 50 25
are reported for traumatic and
Age (n = 75)
non-traumatic cases is denoted
in parenthesis. Analyses   Mean ± SD, range (years) 42 ± 20, 0.006–89 46 ± 19, 0.006–89 35 ± 18, 0.9–75 0.014
performed using the chi-square Gender (n = 75)
test for categorical values or   Female (%) 18 (24%) 14 (29%) 4 (16%) 0.27
Fisher’s exact test for categories
PMH
with less than five observations,
or t-test for numerical values   Unremarkable (n = 55) 29 (53%) 15 (37%) 14 (88%) 0.0016
with alpha < 0.05 being   Coagulopathy* (n = 46) 4 (9%) 3 (12%) 1 (5%) 0.62
statistically significant (denoted PMH conditions (n = 26)
in bold)
 Cardiovascular 27 (61%) 24 (62%) 3 (60%) 1.0
  HTN 18 (41%) 17 (44%) 1 (20%)
  Stroke 2 (5%) 2 (5%) -
  DVT 1 (2%) 1 (3%) -
  Thalassemia minor 1 (2%) 1 (3%) -
   Venous stasis ulcers 1 (2%) 1 (3%) -
  CHF 2 (5%) 1 (3%) 1 (20%)
  Atrial fibrillation 2 (5%) 1 (3%) 1 (20%)
 Endocrinologic
  DM 7 (16%) 6 (15%) 1 (20%) 1.0
 Cancer
  Rectal adenocarcinoma 1 (2%) 1 (3%) - 1.0
 Other 9 (20%) 8 (21%) 1 (20%) 1.0
   Hepatitis B/C virus 2 (5%) 1 (3%) 1 (20%)
  OSA 1 (2%) 1 (3%) -
  PE 1 (2%) 1 (3%) -
  Asthma 1 (2%) 1 (3%) -
  Depression 1 (2%) 1 (3%) -
  GERD 1 (2%) 1 (3%) -
  Migraine 1 (2%) 1 (3%) -
  Quadriparesis 1 (2%) 1 (3%) -

Abbreviations: CHF, congestive heart failure; DM, diabetes mellitus; DVT, deep venous thrombosis;
ESRD, end-stage renal disease; HTN, hypertension; GERD, gastroesophageal reflux disease; MI, myocar-
dial infarction; OSA, obstructive sleep apnea; PE, pulmonary embolism; PMH, past medical history; SD,
standard deviation
*Yes, if patient was reported to be on anticoagulant or antiplatelet agents, or had a known bleeding disorder

difference, and total volume ranged from 16.2 to 30 mL per
side. In all three patients, draining catheters were left in
place on both sides with subsequent thrombolysis and clot
aspiration. BG hemorrhage was larger on the left side in one
case and the right side in two cases. The patient with the
greater hemorrhage on the left side was left with non-fluent
aphasia post-operatively.
Urokinase dissolved in normal saline was used in two
patients with associated intraventricular hemorrhage. In an
older adult (57 year old female), 5000 IU urokinase in 3 mL
normal saline was administered every 12 h for up to 4 doses,
whereas in a child (6 year old male), 8000 IU urokinase
in 3 mL normal saline was administered every 8 h over 2
days. In both cases of urokinase irrigation, complications
related to the procedure arose. In the first adult case, signs of
intracranial hypertension were observed 1.5 h after clamping
the catheter following the initial urokinase infusion (20,000
IU in 3 mL normal saline), which was relieved upon opening
the catheter valve. This prompted a change in administration
schedule to urokinase infusion every 12 h for up to 4 doses
(presumably 5000 IU each). In the second pediatric case,
severe brain swelling developed 2 days following hematoma
evacuation and 1 day after the administration of 8000 IU of
urokinase in 3 mL of normal saline every 8 h. This prompted
a decompressive huge craniectomy and duroplasty with ven-
triculoperitoneal shunting and cranioplasty at post-operative
day 39.
Patients stayed in the hospital for a mean of 19 days
overall (Table 6). This was shorter in the traumatic group
than in the non-traumatic group (16 vs. 21 days, p=0.21).

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Neurosurgical Review (2023) 46:135 Page 13 of 24  135

Table 3  Clinical characteristics. The number of patients for which square test for categorical values or Fisher’s exact test for categories
values are reported for traumatic and non-traumatic cases is denoted with less than five observations, or t-test for numerical values with
in parenthesis (n = no. of cases). Analyses performed using the chi- alpha < 0.05 being statistically significant (denoted in bold)
Categories Overall Non-traumatic Traumatic p-value

Signs and symptoms (n = 54)

 Constitutional 17 (15%) 16 (16%) 1 (6%) 0.70
  N/V 8 (7%) 7 (7%) 1 (6%)
  Fever 4 (3%) 4 (4%) -
  Cough 2 (2%) 2 (2%) -
  Malaise 2 (2%) 2 (2%) -
  Dyspnea 1 (1%) 1 (1%) -
 Neurologic 19 (16%) 17 (17%) 2 (13%) 1.0
  Headache 13 (11%) 11 (11%) 2 (13%)
  Seizures 4 (3%) 4 (4%) -
  Dizziness 1 (1%) 1 (1%) -
  Urinary incontinence 1 (1%) 1 (1%) -
  System deficits 55 (47%) 49 (49%) 6 (38%) 0.60
   Visual 6 (5%) 6 (6%) -
   Speech, language, swallowing 8 (7%) 8 (8%) -
   Sensory 5 (4%) 5 (5%) -
   Motor 30 (26%) 26 (26%) 4 (25%)
    Weakness 12 (10%) 10 (10%) 2 (13%)
    Hypertonia 6 (5%) 6 (6%) -
    Hypotonia 3 (3%) 3 (3%) -
    Tremors 1 (1%) - 1 (6%)
    Other* 2 (2%) 1 (1%) 1 (6%)
   Coordination 2 (2%) 2 (2%) -
   Gait 3 (3%) 1 (1%) 2 (13%)
   Reflexes 30 (26%) 24 (24%) 6 (38%) 0.22
    Positive Babinski 13 (11%) 10 (10%) 3 (19%)
    Impaired PLR 8 (7%) 6 (6%) 2 (13%)
    Hyperreflexia 4 (3%) 3 (3%) 1 (6%)
    Hyporeflexia 3 (3%) 3 (3%) -
    Absent brainstem reflexes 2 (2%) 2 (2%) -
 Other 2 (2%) 1 (1%) 1 (6%) 0.24
  Abdominal pain 1 (1%) 1 (1%) -
  Hypersalivation 1 (1%) - 1 (6%)
  Vitals and labs
  BP (n = 41)
  WNL 15 (36%) 3 (13%) 12 (66%) 0.0016
   Systolic mean ± SD, range 160 ± 41, 69–230 162 ± 41, 69–220 153 ± 43, 100–230 0.63
   Diastolic mean ± SD, range 92 ± 20, 43–140 93 ± 21, 43–140 91 ± 19, 60–118 0.88
  Glucose (mg/dl) (n = 25)
  WNL 16 (64%) 6 (50%) 10 (77%) 0.16
   Mean ± SD, range 170 ± 122, 25–404 199 ± 145, 25–404 115 ± 14, 106–132 0.37
GCS (n = 40)
  At admission 7 ± 4, 3–15 6 ± 4, 3–14 8 ± 4, 3–15 0.046
LOC at admission (n = 75)
 Awake 13 (17%) 9 (18%) 4 (16%)
 Confused 3 (4%) 3 (6%) -
 Disoriented 1 (1%) 1 (2%) -
 Lethargic 8 (11%) 5 (10%) 3 (12%)
 Stuporous 3 (4%) 2 (4%) 1 (4%)
 Comatose 42 (56%) 26 (52%) 16 (64%) 0.28
  Altered, NOS 5 (7%) 4 (8%) 1 (4%)

*Includes 1 limb ballism in the traumatic group, and 1 bradykinesia in the non-traumatic group
Abbreviations: GCS, Glasgow Coma Scale; LOC, level of consciousness; NOS, not otherwise specified; N/V, nausea/vomiting; PLR, pupillary
light reflex; WNL, within normal limits; SD, standard deviation

13

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 135   Page 14 of 24
Follow-up duration was a mean of 8 months. Most patients
were alive (78%). Of patients who were deceased, the overall
survival was a mean of 0.2 months (6 days). Among cases
that reported prognosis, most patients had a poor outcome
(dead, vegetative state, or severe disability) (56%). A signifi-
cantly higher proportion of good recovery was observed in
the traumatic group (48% vs. 17%, p=0.019). Among cases
of surgical intervention with reported outcomes (n = 10),
patients were dead (20%), remained in a vegetative state
(40%), or were severely (20%) or moderately (20%) disabled.
Discussion
The BG is the most commonly reported location for non-
traumatic ICH, with the putamen being implicated in nearly
a third of cases on imaging series [82]. However, BBGH
is a rare occurrence limited to case reports and brief case
series. Based on the presence of trauma, BBGH has been
categorized as traumatic or “non-traumatic” in etiology,
with the latter being associated with a variety of vascular,
chemical, infectious, and endocrinologic triggers. The deep-
seated nature of these lesions and often acute presentation
of loss of consciousness raise questions as to whether neu-
rosurgical intervention can bring any meaningful change
to outcomes. The bilateral nature of the bleed also presents
unique factors that should be taken into consideration dur-
ing management. In this systematic review, we assess the
literature on BBGH and discuss the etiologies, management
strategies, and clinical outcomes.
Etiology
The BG are a collection of deep subcortical gray matter
structures that typically consist of the caudate nucleus, puta-
men, nucleus accumbens, globus pallidus, substantia nigra,
and subthalamic nucleus. Blood supply arises from anterior
circulation via the lenticulostriate arteries of primarily the
middle and sometimes anterior cerebral arteries, with slight
variations from person to person. The anterior choroidal
artery of the internal carotid artery provides further vascu-
lar supply to BG [83–85]. Selective BG hemorrhage is likely
possible due to anatomic and metabolic factors rendering
this region particularly vulnerable to hypoxic and chemical
injury. Specifically, terminal blood supply with a lack of
anastomoses between parenteral vessels [85] and high exci-
totoxic and oxidative stress [86] predisposes the BG to dam-
age following ischemic or toxic insult. Certain individuals
may have an increased risk for hemorrhage due to geometric
feature variations of the middle cerebral artery that promote
wall stress and injury [87], and the presence of other comor-
bid conditions such as hypertension, heart disease, diabetes,
excessive alcohol consumption, and smoking [88, 89].
13
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Neurosurgical Review (2023) 46:135
Understanding the etiology and mechanism of injury
in BG hemorrhage is important to evaluate the benefit, if
any, of surgical intervention, where the principal effects
are related to the dissipation of mass effect and removal of
extravasated blood products. It is perhaps even more crucial
in cases of bilateral hemorrhage, as surgical intervention
presents additional potential risks such as contralateral clot
destabilization or herniation if only one side is aspirated or
increased cortical injury if both sides are targeted. During
primary injury, an expanding hematoma can compress sur-
rounding tissues, including vasculature, potentially altering
blood flow if sufficiently large. However, the extent to which
this occurs in BBGH may be minimized by a stanching effect
of the contralateral hematoma and relative theoretical laxity
of gray matter in this region in comparison to white mat-
ter and the cerebral cortex [90, 91], which may contain the
bleed and limit significant tissue displacement. This remains
speculative as studies on viscoelastic properties of the brain
cannot simulate all aspects of a BBGH in humans [92].
Secondary injury is attributed to the proinflammatory and
neurotoxic effects of thrombin and red blood cell contents
such as hemoglobin, hemin, and iron following cell lysis,
which then can lead to edema with subsequent increased
intracranial pressure and herniation [93, 94].
Traumatic BG hemorrhage is thought to be caused by
tears in branches of the anterior choroidal or lenticulostriate
arteries due to sudden acceleration-deceleration and shear-
ing forces. This was first observed histologically by Mosberg
and Lindenberg upon discovering a ruptured arterial twig
of the anterior choroidal artery in a patient with traumatic
hemorrhage of the left pallidum [95]. Mechanisms by which
bilateral traumatic tears occur are likely due to the same
shearing forces, with anatomical variations in the symme-
try or proximity of vasculature and trajectory of the exter-
nal force perhaps predisposing individuals to simultaneous
rupture of arteries on both sides. Alternatively, hemorrhage
occurring initially on one side with subsequent hematoma
expansion [96, 97] may alter local hemodynamics and cause
mass effect leading to rupture of contralateral arteries lack-
ing normal wall integrity due to damage sustained from the
initial traumatic event. This latter view may be supported
by the appearance of asymmetric hemorrhage volumes and
unilateral symptoms noted in most of our included cases.
Compared to the traumatic unilateral BG hemorrhage series
presented by Boto et al. in 2001 [98], our dataset included a
lower proportion of motor vehicle accident cases (58% vs.
94%). This is likely due to their selection of severe cases
through inclusion of only patients with a GCS score of 8
or less. Our traumatic cases also included etiologies of dif-
fuse nature, such as lightning strike and blast injury, which
to our knowledge has not yet been reported as manifest-
ing with unilateral BG hemorrhage. Thus, traumatic BBGH
will likely share etiologic similarities with unilateral BG
Neurosurgical Review (2023) 46:135 Page 15 of 24  135

Table 4  Hemorrhage Categories Overall Non-traumatic Traumatic p-value

characteristics. The number
of patients for which values Etiology (n = 70)
are reported for traumatic and
 Traumatic
non-traumatic cases is denoted
in parenthesis (n = no. of   MVA 14 (20%) - 14 (58%) -
cases). Analyses performed   Fall 5 (7%) - 5 (21%) -
using the chi-square test for   Assault 2 (3%) - 2 (8%) -
categorical values or Fisher’s
  Blast injury 1 (1%) - 1 (4%) -
exact test for categories with
less than five observations, or   Lightning 1 (1%) - 1 (4%) -
t-test for numerical values with    Penetrating head injury 1 (1%) - 1 (4%) -
alpha < 0.05 being statistically    Spontaneous
significant (denoted in bold)
  Vascular
   HTN 15 (21%) 15 (33%) - -
   Cardiac arrest 4 (6%) 4 (9%) - -
   Venous thrombosis 3 (4%) 3 (7%) - -
   Aneurysm 1 (1%) 1 (2%) - -
   Preeclampsia 1 (1%) 1 (2%) - -
   Migraine 1 (1%) 1 (2%) - -
  Chemical
   Methanol 7 (10%) 7 (16%) - -
   Ethylene glycol 1 (1%) 1 (2%) - -
   Methylmalonic acidemia 1 (1%) 1 (2%) - -
   Olanzapine 1 (1%) 1 (2%) - -
   Toluene 1 (1%) 1 (2%) - -
   Anticoagulants 1 (1%) 1 (2%) - -
   SSRI 1 (1%) 1 (2%) - -
  Infectious
   COVID 2 (3%) 2 (4%) - -
   Japanese encephalitis 2 (3%) 2 (4%) - -
   GBS meningitis 1 (1%) 1 (2%) - -
  Endocrinologic
   DKA 1 (1%) 1 (2%) - -
   HHS 1 (1%) 1 (2%) - -
  Unknown 1 (1%) - 1 (4%) -
Location (n = 75)
  Basal ganglia
 Putamen 32 (39%) 25 (39%) 7 (37%) 1.00
  Globus pallidus 17 (20%) 10 (16%) 7 (37%) 0.073
  Caudate nucleus 7 (8%) 5 (8%) 2 (11%) 0.65
  Basal ganglia, NOS 27 (33%) 24 (38%) 3 (16%) 0.098
Lesion referred As (n = 75)
  ICH (%) 57 (76%) 34 (68%) 23 (92%) 0.023
  Hemorrhagic infarction (%) 16 (21%) 14 (28%) 2 (8%) 0.072
  Hemorrhagic necrosis (%) 2 (3%) 2 (4%) - 1.0
Concurrent hemorrhage (n = 71)
  Yes (%) 17 (24%) 6 (13%) 11 (44%) 0.0074
Hemorrhage volume* (n = 10)
  Mean volume ± SD, range (mL) 22 ± 19, 1–74 27 ± 20, 1–74 15 ± 15, 3–42 0.18

*Volume for one side

Abbreviations: DKA, diabetic ketoacidosis; DM, diabetes mellitus; GBS, group B Streptococcus; HHS,
hyperosmolar hyperglycemic state; HTN, hypertension; MVA, motor vehicle accident; NOS, not otherwise
specified; SSRI, selective serotonin reuptake inhibitor

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 135   Page 16 of 24 Neurosurgical Review (2023) 46:135

Table 5  Management. The Categories Overall Non-traumatic Traumatic p-value

number of patients for which
values are reported for traumatic Management type (n = 72)
and non-traumatic cases is  Conservative 60 (83%) 40 (85%) 20 (80%) 0.82
denoted in parenthesis (n = no. Medical treatment* (n = 39)
of cases). Analyses performed   Pressure management 34 (55%) 18 (58%) 16 (52%) 0.61
using the chi-square test for
ACE inhibitor
categorical values or Fisher’s
exact test for categories with    Enalapril 1 (2%) 1 (3%) -
less than five observations, or   Vasodilator
t-test for numerical values with    Hydralazine 1 (2%) 1 (3%) -
alpha < 0.05 being statistically   Inopressor
significant (denoted in bold)    Dopamine 1 (2%) 1 (3%) -
  DHP CCB
   Amlodipine 1 (2%) 1 (3%) -
   Nimodipine 1 (2%) 1 (3%) -
  Loop diuretic
  Furosemide 5 (8%) 1 (3%) 4 (13%)
  Beta-blocker
  Labetalol 1 (2%) - 1 (3%)
  Combination antihypertensives
  Perindopril/amlodipine 1 (2%) - 1 (3%)
   Irbesartan/hydrochlorothiazide 1 (2%) 1 (3%) -
  Antihypertensives, NOS 4 (6%) 4 (13%) -
  Osmotic agents
  Glycerin 1 (2%) 1 (3%) -
   Hypertonic saline 2 (3%) - 2 (6%)
   Human albumin 1 (2%) 1 (3%) -
   Mannitol 9 (15%) 1 (3%) 8 (26%)
   Osmotic diuretic, NOS 2 (3%) 2 (6%) -
   Antiedema, NOS 2 (3%) 2 (6%) -
 Pain
  Naproxen 1 (2%) 1 (3%) -
 Antiepileptics 10 (16%) 2 (6%) 8 (26%) 0.081
  Phenytoin 7 (11%) 1 (3%) 6 (19%)
  Antiepileptic, NOS 3 (5%) 1 (3%) 2 (6%)
  Thrombolytics
  Urokinase 3 (5%) 2 (6%) 1 (3%) 1.0
  Anticoagulant 4 (6%) 4 (13%) -
  Nafamostat mesilate 1 (2%) 1 (3%) -
  Heparin 3 (5%) 3 (10%) -
Other 10 (16%) 4 (13%) 6 (19%) 0.73
  Haloperidol 1 (2%) - 1 (3%)
  Statin 2 (3%) 2 (6%) -
  Steroid 2 (3%) 2 (6%) -
  Benzodiazepine 4 (6%) - 4 (13%)
  Phenobarbital 1 (2%) - 1 (3%)
Surgical treatment (n = 11)
  Hematoma evacuation** 6 (55%) 4 (67%) 2 (40%) 1.0
  Decompressive craniectomy*** 3 (27%) 1 (17%) 2 (40%) 0.30
  Third ventriculostomy 1 (9%) 1 (17%) - -
  ICP monitor 1 (9%) - 1 (20%) -

*Does not report detoxification agents (e.g., dialysis, fomepizole), vitamins (e.g., folate), or specific treatments for etiologies asso-
ciated with the onset of BBGH (e.g., antibiotics for infection) other than vascular or pressure management
**Includes 2 EVDs (1 traumatic, 1 non-traumatic)
***Includes 1 case of external decompression with debridement of cerebral contusion and removal of bone fragments
(traumatic)
Abbreviations: ACE, angiotensin-converting enzyme; CCB, calcium channel blocker; DHP, dihydropyridine; ICP, intrac-
ranial pressure; NOS, not otherwise specified

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Neurosurgical Review (2023) 46:135 Page 17 of 24  135

Table 6  Outcomes. The number Categories Overall Non-traumatic Traumatic p-value

of patients for which values
are reported for traumatic and Length of stay (n = 43)
non-traumatic cases is denoted
  Mean days ± SD, range 19 ± 14, 1–73.5 21 ± 16, 1–73.5 16 ± 12, 3–39 0.21
in parenthesis (n = no. of
cases). Analyses performed Follow-up (n = 29)
using the chi-square test for   Mean months ± SD, range 8 ± 8, 0.2–25 9 ± 8, 0.2–24 7 ± 8, 0.5–25 0.49
categorical values or Fisher’s Status (n = 73)
exact test for categories with
  Alive (%) 57 (78%) 36 (75%) 21 (84%) 0.56
less than five observations, or
t-test for numerical values with Overall survival (n = 11)
alpha < 0.05 being statistically   Mean months ± SD, range 0.2 ± 0.2, 0–0.8 0.3 ± 0.3, 0–0.8 0.2 ± 0.06, 0.1–0.2 0.38
significant (denoted in bold) Prognosis (n = 64)
  Good recovery 18 (28%) 7 (17%) 11 (48%) 0.019
  Moderate disability 10 (16%) 7 (17%) 3 (13%) 1.0
  Severe disability 13 (20%) 10 (24%) 3 (13%) 0.35
  Vegetative state 7 (11%) 5 (12%) 2 (9%) 1.0
 Dead 16 (25%) 12 (29%) 4 (17%) 0.37

Abbreviations: SD, standard deviation

hemorrhage, but may include events where trauma is sudden, Management

diffuse, and more uniform.
Non-traumatic BG hemorrhage is associated with a
variety of etiologies. Hypertension is the predominant
cause with persistent elevations in arterial pressure asso-
ciated with lipohyalinosis and weakening of small vessel
walls, which may lead to occlusion and ischemia (lacunar
stroke) or breach and hemorrhage [99]. Some cases are
hypothesized to occur from a sudden rise in blood pressure
causing rupture of microaneurysms or tears in the len-
ticulostriate artery branches [100]. Other potential causes
include toxic metabolites of alcohols and glycols, antico-
agulation therapy, vessel wall abnormalities (“no-reflow
phenomenon”) or focal necrosis following ischemia, cer-
ebral venous thrombosis in the great cerebral vein, and
migraine-induced vascular changes. In our dataset, vas-
cular and ischemic etiologies accounted for most cases
(53%), though chemical, infectious, and endocrinologic
factors were implicated in nearly half of the other cases
and underscore the importance of inquiring about suicidal
ideation, COVID-19 vaccination status and exposure, and
glucose control in the setting of diabetes mellitus from
reliable historians. The role of COVID-19 infection in
BBGH may be related to hypercoagulopathy [101] or
neurotropism [102] though future studies will be needed
to explore this association further. Etiologies among uni-
lateral and bilateral BGH are likely similar, though it is
unclear if BBGH has higher proportions of certain etiolo-
gies as epidemiological studies of specific BGH causes are
difficult to perform.
Management of BBGH was predominantly conservative,
resembling current themes of management in ICH and uni-
lateral BGH cases. Options for management of BG hem-
orrhage include medical therapies or surgical intervention
with the goal of removing the hematoma, limiting hematoma
expansion, ICP monitoring, or minimizing consequences
of secondary injury though the role of surgery remains
controversial [103–105]. Several clinical trials have been
conducted to explore each of these therapeutic approaches
predominantly in the setting of non-traumatic ICH. None
have demonstrated a clear benefit of surgery, though several
limitations must be taken into consideration when apply-
ing these findings to cases of deep-seated BG hemorrhage.
In 2005, the Surgical Trial in Intracerebral Haemorrhage
(STICH) [14] evaluated the impact of early surgery (within
72 h) versus conservative treatment in patients with non-
traumatic supratentorial ICH. One of the major limitations
of this trial was in the inclusion of both lobar (39%) and
BG (42%) hemorrhage within the same group and analysis.
Lobar and BG hemorrhage differ markedly, with BG hemor-
rhage causing permanent damage to critical gray matter in
the immediate vicinity of the bleed. Additionally, compared
to lobar locations, hemorrhages of the BG are at higher risk
for intraventricular extension and are associated with greater
morbidity and mortality [106]. The lack of clear surgical
benefit noted in the STICH trial may be attributed to the
permanence of deficits upon BG hemorrhage as surgical
intervention cannot restore what was lost. Most surgeons in

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 135   Page 18 of 24
the trial employed a craniotomy (75%), despite nearly 42%
of hematoma originating within the BG or thalamus, raising
questions as to whether a more minimally invasive surgical
approach would lead to better outcomes [107]. Early surgery
was associated with a slightly favorable outcome when the
hematoma was located within 1 cm from the cortical surface,
which may have been a reflection of the advantages of crani-
otomy for superficial resection, though when this subgroup
was explored in a follow-up trial (STICH II) in 2013 [15],
the findings remained neutral.
Minimally invasive strategies for evacuating hemorrhages
in deep locations such as the BG would be preferred over a
craniotomy. This approach was assessed in the MISTIE trials
(Minimally Invasive Surgery with Thrombolysis in Intrac-
erebral Hemorrhage) [108], which provided a protocol for
image-guided aspiration followed by thrombolysis of the clot
with alteplase administration every 8 h for up to nine doses.
In 2019, MISTIE III [13] evaluated the impact of MISTIE
treatment versus standard medical care on functional out-
comes based on the modified Rankin Scale score at 1 year.
MISTIE treatment was not associated with improvements in
functional outcome; however, only 58% of cases met the clot
reduction goal of less than 15 mL. Subsequent analysis of
subjects that received adequate hematoma removal accord-
ing to the surgical target of less than 15 mL demonstrated
slight positive benefit in outcome compared to controls, and
further studies with more consistent surgical results are war-
ranted. Several smaller studies have evaluated the role of
other minimally invasive surgical techniques, with mixed
results on the benefit of such interventions on overall out-
comes [18, 109–113].
Although studies on the impact of surgical evacuation of
non-traumatic ICH are generally neutral, a 2018 meta-analy-
sis with 15 published randomized controlled trials investigat-
ing minimally invasive surgery [114] found that it improved
morbidity and mortality significantly more than medical
management or craniotomy, nearly doubling the chance of
independence and survival and follow-up. Though this does
not include recent results from MISTIE III, minimally inva-
sive strategies show promise, especially when surgery can be
performed within 72 h of symptom onset in certain patient
subgroups such as those with moderate hematoma volume
20–50 mL and GCS ≥ 9 [17]. The 2022 American Heart
Association/American Stroke Association (AHA/ASA)
guidelines for management of patients with spontaneous
ICH reflect this with a moderate strength recommendation
in regard to minimally invasive hematoma evacuation for
patients with supratentorial ICH of > 20–30 mL with GCS
scores of 5–12 [115]. However, the guidelines do not spec-
ify etiology or location, and it will be difficult to ascertain
benefit for BBGH until future studies investigate minimally
invasive strategies for unilateral BGH. In the coming years,
two industry-sponsored randomized controlled trials, Early
13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Neurosurgical Review (2023) 46:135
Minimally Invasive Removal of Intracerebral Hemorrhage
(ENRICH) sponsored by the NICO corporation, and Mini-
mally Invasive Endoscopic Surgical Treatment with Apollo/
Artemis in Patients with Brain Hemorrhage (INVEST) spon-
sored by Penumbra, will add to the minimally invasive surgi-
cal literature. Meanwhile, the Swiss Trial of Decompressive
Craniectomy Versus Best Medical Treatment of Spontane-
ous Supratentorial Intracerebral Hemorrhage (SWITCH)
will provide information on the importance of strict control
of intracranial hypertension with prophylactic decompres-
sive craniectomy in patients with non-traumatic ICH in the
BG and/or thalamus.
Evidence for surgical intervention in cases of traumatic
ICH remains scarce, with only one randomized controlled
trial published to date that was terminated prematurely due
to recruitment and funding issues. The Surgical Trial in
Traumatic Intracerebral Hemorrhage (STITCH) [12] was
the first to investigate the impact of surgery in traumatic
cases. Most surgeons opted to use craniotomy (97%) and the
largest areas of hemorrhage were in the frontal or temporal
lobes (92%). Although there were significantly more deaths
in the first 6 months in the conservative treatment group
(33% vs. 15%), sample sizes were low (n = 170). Since most
cases involved lobar regions, it is difficult to translate these
findings to traumatic BG hemorrhage. Surgical management
of traumatic BG hemorrhage will likely depend on stud-
ies evaluating the role of minimally invasive approaches for
non-traumatic ICH located in deep regions.
Taken together, these studies support conservative man-
agement for ICH especially when the hematoma resides
in deep areas such as the BG, though timely minimally
invasive surgery between 4 [116] and 72 h after the incit-
ing event may be beneficial in cases where hematoma
volume is moderate (20–50 mL) and GCS is above 9, and
decompressive craniectomy may be considered for cases of
impending herniation or neurologic worsening attributed
to mass effect. Another factor to take into consideration
is the laterality of the bleed in relation to the dominant
cerebral hemisphere. Surgical evacuation on the dominant
side may cause new post-operative aphasia, making less
invasive approaches such as a decompressive craniectomy
more favorable. Unfortunately, our dataset was severely lim-
ited in the number of surgical cases and surgical detail and
determining whether the cause of post-operative aphasia is
surgical intervention, or the inciting event may be challeng-
ing due to altered level of consciousness at admission, pre-
venting an accurate assessment of speech and hemispheric
dominance. Future studies reporting laterality of the surgi-
cal approach and post-operative deficits are needed. Limited
evidence is thus available to determine whether surgical
intervention on one or both sides of a BBGH confers any
benefit on outcome. Medical management, particularly the
use of antihypertensives for early blood pressure lowering
Neurosurgical Review (2023) 46:135 Page 19 of 24  135
(systolic blood pressure 130–150 mmHg) as described in
the American Heart Association/American Stroke Associa-
tion guidelines [115], will likely remain the mainstay of
treatment for most BBGH cases.
Outcomes
Outcomes of BBGH were dismal. More than half of patients
experienced vegetative state, severe disability, or death
(56%), while only 28% experienced what was deemed good
recovery though follow-up was limited with an average
time of 8 months. Overall mortality rates were 25% and all
occurred within the first month. Although this appears to be
lower than ICH mortality rates of 40% at 1 month and 54% at
1 year [1, 88], BBGH appears to have higher mortality rates
than unilateral basal ganglia hemorrhage cases in general
(25% vs. 16%) [19]. Compared to literature reports of mostly
unilateral cases, BBGHs have higher mortality rates among
non-traumatic BGH (29% vs. 13–19% [117, 118]) even in
cases complicated with severe intraventricular hemorrhage
(29% vs. 24–28% [119]). However, BBGH cases appear to
have lower mortality rates among traumatic BGH (17% vs.
35–52% [120–123]) cases. One possibility for these differ-
ences in outcomes between bilateral and unilateral disease
is that in non-traumatic cases, BBGH correlates with greater
burden of disease. However, in traumatic cases, BBGH may
relate more to the direction or nature (e.g., diffuse, uniform)
of external force rather than the intensity of impact. Assum-
ing that patients with vegetative state, severe disability, or
death correspond to a modified Rankin Scale (mRS) of at
least greater than 3, spontaneous BBGH cases also appear
to be associated with worse functional outcomes than spon-
taneous unilateral cases (65% vs. 30–50% [118, 124]).
The traumatic BBGH group tended to do better than the
non-traumatic group in terms of shorter average length of
stay, higher proportion of patients alive, and significantly
higher proportion of patients experiencing good recovery at
follow-up. This echoes findings from other studies comparing
traumatic and non-traumatic ICH. In 2002, Siddique et al.
found that traumatic ICH cases were associated with better
outcomes (good recovery and moderate disability) than those
with non-traumatic ICH (67% vs. 24%) [125]. It should be
noted that traumatic hematomas were often more superficial
and lobar (91%) than in the non-traumatic group (56%) which
may have contributed to the starker difference in outcomes
than in our dataset of exclusively deep BG hemorrhages.
Cases of traumatic ICH may have more favorable prognosis
than non-traumatic cases due to the often younger age of
patients which was also reflected in our study (35 vs. 47), and
since the etiology is related to external factors (trauma) rather
than intrinsic factors (e.g., impaired vasculature) that may
also hamper recovery. Specific location within the BG may
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
also be a prognostic factor, as differences in outcomes have
been observed based on which arterial territory is affected
[126] and certain sites such as the putamen have been associ-
ated with a higher frequency and volume of early hemorrhage
expansion [96, 97]. The bilateral nature of hemorrhage raises
questions as to whether the contralateral hematoma in BBGH
assists in stabilizing the clot due to a stanching effect on the
surrounding vessels, though this remains speculative.
Limitations
This review is limited by the retrospective nature of case
reports and case series, lack of consistent and comprehensive
reporting of relevant clinical and surgical details, and differ-
ences in time periods of study which may have introduced
confounding practice and technical factors. The assessment
of prognosis was subjective and scored by the authors based
on the information provided in the text, which ranged from
being a minimal general statement of the patient’s well-being
to a more detailed explanation of exact daily functioning
with examples. Due to the retrospective nature of this review
and differences in granularity from study to study, we could
not evaluate the efficacy of any interventions. The severely
limited number of cases with surgical management and dif-
ferences in surgical detail prevent us from offering indica-
tions and insight into when surgical approaches would be
beneficial and what postcritical management should entail.
While most cases referred to the lesion as an ICH, a minor-
ity of cases referred to the lesion as a hemorrhagic infarct
or hemorrhagic necrosis though the criteria for naming was
not explicitly mentioned. Due to different implications on
prognosis, clarity regarding the nature of the hemorrhage
is important for future studies. This heterogeneity of the
literature highlights the importance of standardizing the
collection and reporting of data across different institutions
worldwide. Case reports and series may also carry report-
ing biases, where authors may be more inclined to report
cases if they are interesting, and thus, data reported from
our cohort may not completely reflect the traumatic or non-
traumatic BBGH population. Although the comparative
analyses detected some significant differences between the
two groups, the limited number of patients with available
data within each group should be taken into account when
considering the clinical power of such findings.
Conclusions
BBGH is a rare occurrence that can be associated with a
wide variety of traumatic, vascular, chemical, infectious,
and endocrinologic factors. The differential should be kept
wide, and management generally follows that of current
13
 135   Page 20 of 24
ICH guidelines with supportive care and early blood pres-
sure management as the mainstays of treatment. Minimally
invasive surgery is promising, though the additional risks
of bilateral surgical hematoma evacuation as compared to
unilateral cases of hemorrhage require stronger evidence in
favor of surgical intervention to be worth pursuing, espe-
cially in cases of deep-seated lesions. The present review
confirms that BG hemorrhages are associated with a poor
prognosis and highlights the gaps in current scores and
guidelines. There is an urgent need for improved assess-
ment tools and recommendations regarding BGH. Future
scores and trials in this field should take into consideration
the specific location of hemorrhage and dominance of the
injured hemisphere.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 10143-0​ 23-0​ 2044-x.
Availability of data and material  The datasets generated and/or ana-
lyzed during the current study are available from the corresponding
author on reasonable request.
Author contributions  All authors contributed to the study conception
and design. The study was conceptualized and supervised by G.E.U.
and P.P. Material preparation, data collection, and analysis were per-
formed by G.W., A.C., and C.O. The first draft of the manuscript was
written by G.W. and V.C., O.B., A.S.H., S.M.P., M.S., S.S.H., B.C.,
G.E.U., and P.P. commented on previous versions of the manuscript.
All authors read and approved the final manuscript.
Declarations  STROK​EAHA.​109.​570168
Ethics approval  As this is a literature review, ethics approval is not
applicable.
Consent to participate  As this is a literature review and no original
data from new patients were collected, consent to participate is not
applicable.
Consent for publication  As this is a literature review and no original
data from new patients were collected, consent for publication is not
applicable.
Competing interests  The authors declare no competing interests.
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