Discussion:
Intracerebral hemorrhage amounts to significant morbidity, mortality and economic burden worldwide and occurs in different areas of the brain.2 Basal ganglia hemorrhage is a subtype of intracerebral hemorrhage and commonly occurs in putamen, internal capsule and thalamus. Unilateral basal ganglia bleed is a frequent encounter in neurosurgical ICU and accounts for 10-15% of all strokes, whereas bilateral basal ganglia hemorrhage(BGH) is seen scarcely ever.4 With only a handful of documented occurrences, spontaneous bilateral BGH is incredibly uncommon. The incidence of spontaneous unilateral BGH is approximately 24.6/100,000 person-year. Multiple simultaneous intracerebral hemorrhage has been documented in 2% of all hemorrhagic strokes.5
Essentially all cases of recorded bilateral involvement of spontaneous BGH are in the adult population. Surprisingly, Nadarajah et al. have documented a case of uncommon dengue viral hemorrhagic encephalitis in a 13-year-old girl.6 Nonetheless, the mean age of spontaneous bilateral BGH is 51.86 ± 15.69 years.4
The mechanism of concurrent occurrence of bilateral spontaneous basal ganglia hemorrhage is unsettled. The tenable pathogenesis is concurrent rupture of bilateral aneurysms on lenticulostriate arteries. The other reasonable process is, initial hemorrhage results in baroreceptor mediated reflex increase in blood pressure, inciting a signal for another microaneurysm in contralateral side to rupture in a brief interval of time.2,7 Nonetheless, uncontrolled hypertension (50%) is one of the causes of spontaneous bilateral BGH, followed by intoxication and metabolic disorders (18.33%), vascular anomalies (16.66%), and infectious agents (10%). These findings are based on a review by Alhashim et al.3
Arteriovenous malformations, vasculitis, bleeding diathesis, anticoagulant use, cerebral venous sinus thrombosis, amyloidosis, aneurysm rupture are the convicted causes that can give rise to multiple intracerebral hemorrhage. Similarly, spontaneous bilateral basal ganglia hemorrhage is often attributed to diabetic ketoacidosis, poorly controlled hypertension, and hyperglycemic hyperosmolar state.7,8,9 The patient’s history in this particular case was inadequately managed hypertension. No other chronic illness was known to have existed previously. Given that the putamen is a common site for hypertensive hemorrhage and no other discernible explanation for the bleeding was found, hypertension is the primary culprit in this instance.
Upon further examination of the literature, Stanley described a case akin to this one with a lightning stroke in a young child.10 In a published case report, Prempalung et al. also connected bilateral basal ganglia bleed to serious methanol poisoning.11 Once again to emphasize that in vulnerable people, invasive cerebral fungal infection is another important factor.12
It has recently been proposed that the COVID-19 infection may be neurotropic through the trans cribriform or hematogenous pathway. Why COVID-19 would be associated with a higher risk of bilateral ganglia hemorrhage is still up for controversy. In spite of this, research has demonstrated that the virus contributes to a hypercoagulable, reactive state that escalates the risk of cerebral hemorrhage.13 In addition to COVID-19 infection basal ganglia is also susceptible to harm by flavivirus and toxoplasma gondii.14
A situation involving both basal ganglia is absurd, a poor result is always expected. Even tiny bilateral intracerebral hemorrhages can have fatal consequences, including tetraparesis, loss of consciousness, pseudobulbar paralysis, paralysis, and aspiration pneumonitis. The diaschisis phenomena and inadequate cerebral blood flow may contribute to the patient’s dismal prognosis.4,15,16 Statistical research revealed the following prognostic factors: total hematoma volume, hematoma distribution, and admission GCS score. Furthermore, some studies also looked at hematoma size as a predictive factor.2
The high morbidity and mortality rate of spontaneous ICH results in a substantial financial burden on social services and health care.3 There is discussion over whether or not to operate on the patient at this point. Depending on the size, some medical professionals choose to remove the hematoma right away, while others would rather wait and do surgery as soon as there is a spike in intracranial pressure.7 The significant global variation in ICH care is proof positive that there is ongoing disagreement. According to a recent comprehensive review and meta-analysis, stereotactic evacuation may be associated with a lower odds ratio for mortality and possibly even a higher chance of independent survival.2 However, the majority of documented instances of spontaneous bilateral BGH were treated conservatively.2,3
A significant number of survivors with ICH have long-term and persistent neurological, cognitive, functional, and adaptive behavioral impairments. 4 These impairments can significantly affect the survivor’s ability to carry out independent daily activities, social integration, and eventual level of independence.4