Subsequent bilateral thalamic haemorrhage

Abstract

Simultaneous or subsequent bilateral thalamic haemorrhage is rare, and most reported cases are from Asian countries. An 80-year-old white Cuban man, with a history of arterial hypertension, suffered sudden onset of right hemiparesis. Computed tomography (CT) scan showed a left posteromedial thalamic haemorrhage. Two days later his condition suddenly deteriorated: blood pressure was 220/105 mm Hg, he was stuporous and tetraplegic, respiration was ataxic, and his gaze was fixed and deviated downward and inward. CT scan showed haemorrhages in both thalami, extending to the ventricles. 32 h later the patient died. There are few previous publications of simultaneous or subsequent bilateral thalamic haemorrhages and this is the first report involving a Hispanic patient. Prognosis in patients with bilateral thalamic haemorrhage is poor, and the mechanism underlying the development of subsequent and symmetrical bleeding is not clear.

BACKGROUND

In 1959 Miller Fisher reported a series of thalamic haemorrhages based on detailed necropsy studies.¹ With the advent of computed tomographic (CT) and magnetic resonance (MR) technology,² it has been possible to diagnose and describe bilateral thalamic haemorrhages in living patients, although intracerebral bleedings are seldom confined to the thalamus itself.^3–12

Recurrent intracerebral haemorrhages are frequent complications of arterial hypertension, but simultaneous or subsequent bilateral thalamic haemorrhages are rare events.⁸ Moreover, the outcome of patients with bilateral thalamic haemorrhages is usually poor, leading to death or severe disability.^8,9

There are few reports in literature, most of them from Asian countries.^6–10,13,14 We report here a Cuban patient with subsequent bilateral thalamic haemorrhage.

CASE PRESENTATION

An 80-year-old white man with history of hypertension and chronic pulmonary obstructive disease suffered a right hemiparesia of sudden onset. Two hours later he was admitted to our stroke unit. On arrival his blood pressure was 220/110 mm Hg, he was alert but disphasic. CT scan showed a left posteromedial thalamic haemorrhage.

The patient’s hypertension was treated with diuretics, β-blockers, and calcium antagonists. The following day his blood pressure was 185/90 mm Hg and his neurologic state was stable, but 24 h later his condition suddenly deteriorated: blood pressure was 220/105 mm Hg, he was stuporous and tetraplegic, respiration was ataxic, and his gaze was fixed and deviated downward and inward. CT scan showed haemorrhages in both thalami, extending to the ventricles (fig 1). Endotracheal intubation was performed and mechanical ventilation was started. The intracranial hypertension was treated with hyperventilation and mannitol, but 32 h later the patient died.

Figure 1.

Non-contrasted cranial computed tomography scan performed after the second cerebral haemorrhage episode. There are bilateral thalamic haemorrhages. The right thalamic haemorrhage is more recent and large. Cerebral ventricles are dilated and filled with blood, predominantly in right lateral ventricle.

DISCUSSION

The incidence of simultaneous bilateral intracerebral haemorrhage occurs in <1 % of patients with intracerebral hemorrhage.¹⁴ In fact, 20–35% of strokes in Asian countries are due to intracerebral haemorrhages, while in western countries intracerebral bleedings are diagnosed in only 10–15% of strokes.^8,9,14,15 The present case is the first report involving a Hispanic patient with subsequent bilateral thalamic haemorrhage.

The remote effects of thalamic haemorrhages include pressure of the hemorrhagic mass and surrounding oedema on adjacent structures, inducing herniation syndromes. Blood degradation products may also produce toxic effects on the nervous tissue.^8,9

Hypertension is the most important aetiological factor for simultaneous multiple intracerebral haemorrhage, and was the cause in about 70.6 % of cases with bilateral thalamic haemorrhage reported in literature. The widespread and prolonged degeneration of intracerebral arterioles predispose patients to develop multiple intracerebral hemorrhages.^6–10,13,14

The mechanism underlying the development of simultaneous multiple intracerebral haemorrhage is not clear, although structural and haemodynamic changes of the first haemorrhage may provoke the second one. Other possible mechanisms of spontaneous bilateral haemorrhage may include the simultaneous rupture of bilateral microaneurysms or a primary rupture of a microaneurysm pursued by secondary haemorrhage from the capillaries and veins, due to circulatory disturbance, or intracranial hypertension affecting the contralateral hemisphere.^8,9

The outcome in patients with bilateral thalamic haemorrhage is usually poor. Only a minority of reported cases have achieved a good recovery, with most patients dying or left with severe neurological disabilities (table 1).^6–10,13,14

Table 1.

Reports from the literature of only 18 patients complaining of simultaneous or subsequent bilateral thalamic haemorrhages, most of them from Asian countries

	Author/year	Age	Sex	Cause	Outcome
1	Shiota 1981*	80	M	Arterial hypertension	Severe disability
2	Tamikeke 1983*	72	M	Arterial hypertension	Dead
3	Azuwa 1988†	51	M	Arterial hypertension	Severe disability
4	Nakasato 1988†	51	M	Arterial hypertension	Good
5	Yakumoto 1989†	19	F	Leukaemia	Dead
6	Erbyuth 1991	58	F	Venous thrombosis	Good
7	Kabuto 1991	80	F	Arterial hypertension	Severe disability
8	Lim 1993*	63	M	Arterial hypertension	Dead
9	Wang 1995	40	M	Venous thrombosis	Good
10	Ogawara 1996†	58	M	Arterial hypertension	Good
11	Dromerick 1997	73	F	tPA treatment	Severe disability
12	Sunada 1999	60	M	Arterial hypertension	Dead
13	Imai 2000	54	M	Arterial hypertension	Severe disability
14	Malandrini 2004	41	M	Vasculitis	Dead
15	Yen 2005	63	M	Arterial hypertension	Dead
16	Yen 2005	69	M	Arterial hypertension	Severe disability
17	Yen 2005	68	F	Arterial hypertension	Severe disability
18	Present case	80	M	Arterial hypertension	Dead

*Japanese literature, cited by Sunada⁸

†Japanese literature, cited by Imai⁹

CT and MR technology facilitates the diagnosis of multiple intracerebral haemorrhage, thus enabling early treatment,^8,16 which is the only way a better outcome can be attained in these patients.

LEARNING POINTS

• Symmetrically located haemorrhages are rare, and most reports are from Asian countries.

• The present case is the first report of a Hispanic patient with a subsequent bilateral thalamic haemorrhage.

• Outcome in patients with bilateral thalamic haemorrhage is usually poor.

• CT and MR technology facilitates the diagnosis of multiple intracerebral haemorrhage, thus enabling early treatment, which is the only way a better outcome can be attained in these patients.