Introduction  

   A spontaneous intracerebral hemorrhage (ICH), which results in a stroke, is more common in Asia than in Europe and the USA, and it usually occurs in one area of the brain. The simultaneous occurrence of hypertensive ICH in different arterial territories is a rare clinical event.⁵⁾ We report a rare case of multiple hypertensive ICH that occurred in the pons extending midbrain and the right basal ganglia. We also include a review of the relevant literature. 

Case Report 

   A semicomatose 74-year-old female was transferred to our hospital by ambulance 30 minutes after onset of symptoms. The patient had been healthy before admission, and her medical history was unremarkable except for a 2-year history of hypertension that had been treated by intermittent medication. 
   On admission, she was afebrile with high blood pressure (200/95 mmHg). Her respiration was tachypneic (28/min) and pulse rate was 60 beats/min. She was semicomatose with Glasgow Coma Scale score 4 (eye opening: 1, verbal: 1, motor: 2) and she had a decerebration posture. Her pupils were isocoric and fixed to light. Deep tendon reflexes were increased in all four extremities and Babinski reflexes were present on both sides. Laboratory investigations, including platelet count, bleeding time, international normalized ratio, activated partial thromboplastin time, coagulation factor assay and peripheral blood smear, were normal. 
   Non-enhanced brain computed tomography (CT) showed ICH in the pons extending midbrain as well as right basal ganglia with intraventricular hemorrhage (Fig. 1). There was no continuity between the intracerebral hematomas. CT angiography did not demonstrate any underlying vascular anomalies that might have resulted in the hemorrhage. 
   The patient was treated conservatively with tracheostomy and tube feeding. Six weeks after admission, she still remained in a vegetative state. 

Discussion 

   Multiple simultaneous intracerebral hemorrhage (ICH) is an unusual event and is associated with hematologic disorders, vasculitis, sinus thrombosis, neoplasm, arteriovenous malformation, anticoagulant therapy, illicit drug use, cerebral amyloid angiopathy, or multiple infarction with hemorrhagic transformation.⁵⁾ Multiple simultaneous ICH occurring in hypertension patients has been reported even less frequently. Moreover, ICH occurring simultaneously in the supra- and infra-tentorial regions is a very rare clinical event. Lin et al.⁴⁾ reported only one case with simultaneous ICH in pons and basal ganglia among 553 hypertensive ICH cases. Bae et al.1 reported that two out of 1045 hypertensive ICH cases had multiple simultaneous ICH in different tentorial regions. In our case, we could not find any potential cause other than hypertension based on history and CT angiography. Furthermore, hematomas are a frequent location of hypertensive ICHs and it make amyloid angiopathy-induced ICH unlikely. Thus, our case is probably related to arterial hypertension. 
   The pathogenic mechanism responsible for multiple simultaneous hypertensive ICH is not clear. However, two possible mechanisms have been suggested. The one mechanism is the chance simultaneous rupturing of two microaneurysms. The other mechanism proposes that the initial hemorrhage can cause a reflex increase in blood pressure and increased intracranial pressure, resulting in rupture of another vessel that is already weakened by chronic arterial hypertension.²⁾⁵⁾⁷⁾ Hickey et al.³⁾ stressed that the vascular degenerative change caused by chronic hypertension, such as lipohyalinosis or miliary aneurysm, is closely associated with the multiple ICH. In our case, the patient presented with semicomatose mentality at first, so the hemorrhage initially may have occurred on the pons. And, untreated hypertension induced vascular degeneration is thought to be major factor in simultaneous ICH. Considering the second mechanism, acute management of arterial pressure after ICH is very important. 
   There were no characteristic initial symptoms or neurological signs which suggested that hemorrhage had occurred in both the supra- and infra-tentorial regions.⁹⁾ Generally, however, patients with multiple simultaneous ICH have poor outcome and high mortality because of severe neurological deficits.²⁾⁷⁾⁸⁾ Hemodynamically, poor cerebral blood flow and the diaschisis phenomenon may contribute to the poor prognosis.⁴⁾ 
   There is no medical consensus as to whether multiple simultaneous ICH should be operated on or conservatively treated. However, the majority of reported multiple ICH cases have been conservatively treated rather than operated upon.²⁾ Surgical treatment for multiple ICH should be determined by the location and maximum axis of the hematoma.⁶⁾ Some authors have suggested that surgical evacuation is necessary when the volume of the cerebellar hematoma is massive, as in case of simultaneous supra- and infra-tentorial hypertensive ICH.⁶⁾⁹⁾ Our patient was treated conservatively considering the location and volume of the hematoma and the patient's clinical state. 

Conclusion 

   A rare case of multiple hypertensive ICH occurring simultaneously in the supra- and infra-tentorial regions was presented. This case merits attention due to its rarity, but more studies are required to determine the underlying mechanism of multiple simultaneous ICH in hypertensive patient and to elucidate the relationship between hypertension and simultaneous ICH. 

REFERENCES

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