Simultaneous left-sided hypertensive putaminal and thalamic haemorrhages.

To cite: Amin OSM, Mahmood MM. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2017219300 DESCRIPTION A woman aged 71 years with hypertension developed sudden severe headache and right-sided weakness. The blood pressure was 210/135 mm Hg. She was drowsy. Examination revealed right-sided upper motor neuron facial weakness, hemiparesis, hemi-anaesthesia and extensor planter reflex. Urgent non-contrast CT brain scan was done as shown in figures 1 and 2. Intracerebral haemorrhage comprises 10–15% of all strokes. Approximately 0.7–5.6% of those patients developed simultaneous two (or more) haemorrhages. These bleeds had occurred in different regions of the brain. Hypertension was the commonest aetiology; rupture of Charcot– Bouchard microaneurysm was the initial event responsible for these haemorrhages. The commonest combination of simultaneous haemorrhages was putaminal–cerebellar; in some series, the commonest combination was the bi-thalamic one. The ipsilateral occurrence of putaminal–thalamic haemorrhages is rare; in our previously published case, the patient developed left-sided putaminal–thalamic haemorrhage. In addition, there is no evidence in the literature to suggest any side predilection for hypertensive bleeds. There were no characteristic initial symptoms or neurological signs that might suggest which haemorrhage had occurred first. The treatment of these multiple haematomas is largely medical and conservative; their surgical evacuation is still controversial. However, surgery may be considered a therapeutic option, depending on the location of the haematoma and its longest axis. The early-term and long-term prognoses are poor; destruction of crossing and non-crossing fibre tracts and bilateral diaschisis might explain this poor outcome.