Dados do Trabalho

Título

Simultaneous Bilateral Hypertensive Thalamic Hemorrhagic – a very rare presentation

RESUMO

Presentation

A 75-year-old woman, hypertensive, diabetic and smoker with irregular treatment, was found unconscious and with signs of sphincter release at home. She was last seen well at 10 am and was admitted at hospital at 11 pm. In the emergency room she had blood pressure 224/127 mmHg, blood glucose 133 mg/dL, SpO2 98%, 3-points Glasgow Coma Scale, miotic pupils.
Her non-contrast computed tomography showed bilateral thalamic hemorrhage. Cranial CT angiography showed no vascular malformations and cranial magnetic resonance imaging showed age-matched bilateral hemorrhage, in addition to deep cerebral microbleeds, bilateral periventricular microangiopathy and ischemic lesions with lacunar aspect of indeterminate date.
She was managed conservatively and at the time of publication of this case she is still in a comatose state with a 7-point Glasgow Coma Scale.

Discussion

Hemorrhagic stroke has an estimated prevalence of 12-15% of all strokes. The most common etiologies include amyloid and hypertensive angiopathy. Considering hypertensive angiopathy, the main sites of hemorrhage are the basal ganglia, thalamus, pons and cerebellum. Hemorrhage in the thalamus represents less than 25% of hemorrhagic strokes and the simultaneous involvement of these structures is even rarer. To date, there are less than 15 case reports worldwide of bilateral thalamic hemorrhage. The pathophysiology is still uncertain but is related to the rupture of microaneurysms or perforating arteries chronically injured by uncontrolled hypertension.

Final Comments

Our patient had an atypical presentation of bilateral thalamic hemorrhage. It is necessary to exclude important differential diagnoses such as cerebral venous thrombosis with hemorrhagic infarction, vascular malformations and even ischemic stroke with hemorrhagic transformation for the treatment be performed properly. Some clues that may help in the diagnosis include the spectrum of small vessel disease such as periventricular microangiopathy, deep cerebral microbleeds and previous ischemic lacunar lesions. We hope that this case report can help other colleagues in the future who are faced with the same radiological images.

Palavras Chave

Stroke hypertensive thalamic hemorrhagic