ICH is one of the most deadly stroke subtypes and accounts for 10–15% of all strokes. It is the second most common subtype of stroke; it is second to ischaemic stroke in frequency.1–3
The list of causes of non-traumatic ICH is long, but chronic hypertension ranks first on this list and comprises at least 50% of the causes; it is the most important potentially modifiable risk factor for this devastating vascular event.4–7
Thrift et al
studied 331 consecutive patients with haemorrhagic stroke and found that chronic hypertension more than doubled the risk of developing ICH.8
Chronic arterial hypertension results in a necrotising type of arteriopathy with fibrinoid degeneration and lipohyalinosis, and gradually ends in the formation of Charcot-Bouchard micro-aneurysms. The sudden rupture of these micro-aneurysms results in ICH. These changes predominantly affect the territory of penetrator arteries that branch off major intracerebral arteries often at 90 ° with the parent vessel; lenticulostriates, thalamoperforators, superior cerebellar and paramedian branches of the basilar artery are the usual targets.9
Approximately 80% of all ICHs occur in the supratentorial area, while the rest (20%) develop infratentorially.10
According to Weisberg et al
the most common sites of primary ICH (in order of decreasing frequency) are the putamen and adjacent internal capsule (which comprises 50% of cases); the central white matter of the temporal, parietal or frontal lobes (lobar haemorrhages); the thalamus; a cerebellar hemisphere and the pons.
Our patient developed simultaneous right-sided putamenal and deep cerebellar haemorrhages. Adams and Victor12
found that such simultaneous ICHs occur in 2% of all primary spontaneous hypertensive ICHs. However, Tanno et al13
studied 679 cases of hypertensive ICH and found that 0.7% of their patients presented with simultaneous or multiple ICHs. However, Uno et al14
encountered only nine cases between May 1976 and December 1989. Between January 1990 and November 2002, Shiomi et al15
evaluated 1069 cases of primary hypertensive ICH; only 11 cases presented with simultaneous haemorrhages—a figure that constituted 1% of their cases.
The locations of our patient's haematomas were putamenal and cerebellar. According to Shiomi et al
this combination is the most common as five out of their eleven cases had such haematomas; the rest were in the pons and basal ganglia in four patients and subcortical and basal ganglia in another two cases. When simultaneous supra- and infra-tentorial haematomas develop, Uno et al14
found that the commonest site for the infratenorial haematomas was the cerebellum and that the putamen was the main target for supratenotrial haematomas.
The available literature12–16
does not mention whether the right side of the brain is more commonly involved than the left one, and whether the haematomas are usually ipsilateral or contralateral to each other. In addition, there were no characteristic initial symptoms or neurological signs that might suggest which haemorrhage had occurred first; the only exception was that prominent initial cerebellar symptoms and signs might indicate that the initial haemorrhage was the cerebellar one, as in our patient.
As for the possible mechanism behind the development of simultaneous/multiple hypertensive haemorrhages, Tanno et al
and Shiomi et al13 15
suggested that the bleeding might have occurred simultaneously in different regions of the brain, or that the initial bleeding was followed after a short time by a secondary one at another site due to high intracranial pressure and circulatory disturbance.
Our patient's putamenal haematoma was relatively large while the cerebellar one was fortunately small and deep and did not compress the fourth ventricle or the brainstem. According to Shiomi et al
the surgical treatment for multiple haematomas should be determined by the location and maximum axis of the haematoma and he proposed that cerebellar haematomas should be removed if the supratentorial haematoma is small. This is consistent with Uno's opinion14
who suggested that haematoma evacuation is necessary when the cerebellar haematoma is bigger than the supratentorial one.
In general, the prognosis is poor both short-term and long-term.13
However, if the neurological grading is 1–3 at the time of presentation, the outlook is usually good whether conservative or surgical treatments were used; if this grading is 4–5, the prognosis becomes poor no matter which treatment modality is used.14
- Simultaneous hypertensive ICHs are rare but carry a considerable morbidity and mortality.
- The haematomas may develop at the same time due simultaneous rupture of Charcot-Bouchard micro-aneurysms in different places of the brain, or one haematoma develops and is followed by the other one after a short time.
- It is difficult to decide which haematoma was the very first one.
- Haematoma evacuation is necessary when the cerebellar haematoma is bigger than the supratentorial one.
- In general, the outlook is poor in most patients.