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