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Título

Perimesencephalic Hemorrhage: a rare entity with possible complications

RESUMO

A 37-year-old woman, previously healthy, was admitted with a 5-day history of occipital and nuchal headache with irradiation to the back, inedit, progressing to worst intensity in 5 to 10 minutes, with nausea associated. It was also evidenced by high blood pressure (220x130 mmhg). 3 days after the initial symptoms, she had mental confusion and irritability. The neurological examination revealed neck stiffness and parisia of the right lateral rectus. A brain non contrast computerized tomography (NCCT) was performed - we found hyperdense images near the mesencephalic cisterns. Then we performed a digital subtraction angiography (DSA), which was normal. The following day, the patient presented worse of mental confusional, papilledema, complete ophthalmoplegia in the right eye and parisia of the lateral rectus in the left eye. A brain magnetic resonance imaging (MRI) showed multiple areas of restricted diffusion in the occipital lobe, bilateral cerebellar and right front. A MRI angiography with vessel wall was performed and showed multiple stenotic focus in large vessels (ACID, ACMD, ACPD), and fine enhancement still on their walls. Based on these findings, and considering the severity and aggressiveness of this disease, we treated her for central nervous system (CNS) vasculitis with pulse therapy (methylprednisolone 1 gram for 5 days). After the third day, the patient improved her mental confusion and her ophthalmoplegia. In order to evaluate if the patient’s improvement was related to radiologic findings, we therefore submitted her to another DSA. The findings were related to cerebral vasospasm than to CNS vasculitis. 25 days after the initial symptoms, we performed a new DSA, which was normal. Her final diagnosis was delayed cerebral ischemia (DCI) due to a perimesencephalic hemorrhage (PMH).
The PMH’s clinical features described in some reviews were headache with instantaneous or more gradual onset, accompanied by nausea and vomiting. It’s rare, but can also present with loss of consciousness, transient focal symptoms or epileptic seizure. Complications are not common, but can occur hydrocephalus, DCI, rebleeding, amnesia and cranial nerve palsies. The diagnoses of PMH can be done with a NCCT.
MPH with short term complications are rare and long-term outcome is excellent. Although it is a condition that remains underdiagnosed. We understand very few aspects of this condition. But knowledge about this disease is still under development.

Palavras Chave

PERIMESENCEPHALIC HEMORRHAGE;
MRI VESSEL WALL;
DELAYED CEREBRAL ISCHEMIA;
CNS VASCULITIS