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Basal Ganglia Hemorrhage

Basal ganglia hemorrhage is one of the more common types of deep intracerebral hemorrhages. It may occur on the grounds of pre-existing hypertension, or in the setting of trauma. In addition to the classical symptoms - nausea, vomiting, and headaches, cognitive impairment and movement disorders are also seen. A thorough clinical observation and imaging studies, primarily computed tomography, are used to make the diagnosis.


Presentation

Together with the internal capsule, the basal ganglia are one of the most frequent sites of intracerebral hemorrhage, comprising between 35%-70% of all cases [1]. Basal ganglia hemorrhage predominantly develops in the presence of several risk factors, most important being long-standing hypertension (vascular malformations, tumors, other cardiovascular diseases or an aneurysm are additional predisposing risks), whereas traumatic, although much rarer, is a less common but still important cause [1] [2] [3] [4]. The clinical presentation of hemorrhagic lesions in the brain encompasses several nonspecific features - nausea, headache, vomiting and altered mental state, but several authors have described specific focal neurological deficits in the setting of basal ganglia hemorrhage [1] [2] [4] [5]. Cognitive impairment, altered perception and emotional processing, and even depression have been reported in lesions of the basal ganglia, whereas a range of movement disorders are described in these patients as well [4] [6] [7]. Dystonia, asterixis, chorea and hypokinesia are reported after basal ganglia stroke, but restless leg syndrome (RLG), distinguished by a rather unpleasant sensation in the lower extremity, is particularly associated with basal ganglia hemorrhage [7] [8]. It must be pointed out that trauma may often lead to injury of other brain areas (particularly in the setting of bilateral basal ganglia hemorrhage) [2] [3], meaning that a range of other neurological manifestations can be present, depending on the site of injury.

Arm Pain
  • He could not see or touch the phantom arm but he felt the presence of an addition arm lateral to his paretic arm. Pain or sensory discomfort were absent in either the paretic arm or the phantom arm.[ncbi.nlm.nih.gov]
Hyperthermia
  • During the patient's hospital course, he developed tachypnea, diaphoresis, hypertension, hyperthermia, and tachycardia for three consecutive days.[ncbi.nlm.nih.gov]
Tachypnea
  • During the patient's hospital course, he developed tachypnea, diaphoresis, hypertension, hyperthermia, and tachycardia for three consecutive days.[ncbi.nlm.nih.gov]
Asterixis
  • Dystonia, asterixis, chorea and hypokinesia are reported after basal ganglia stroke, but restless leg syndrome (RLG), distinguished by a rather unpleasant sensation in the lower extremity, is particularly associated with basal ganglia hemorrhage.[symptoma.com]
Tachycardia
  • During the patient's hospital course, he developed tachypnea, diaphoresis, hypertension, hyperthermia, and tachycardia for three consecutive days.[ncbi.nlm.nih.gov]
Restless Legs Syndrome
  • Dystonia, asterixis, chorea and hypokinesia are reported after basal ganglia stroke, but restless leg syndrome (RLG), distinguished by a rather unpleasant sensation in the lower extremity, is particularly associated with basal ganglia hemorrhage.[symptoma.com]
Tremor
  • Symptoms The symptoms caused by the basal ganglia hemorrhage are present at different levels, as you will have the opportunity to see below: Body movement Difficulties swallowing, smiling or speaking Ataxia Tremor Loss of movement/rigid movements Paralysis[hellomrdoctor.com]
  • Stiff, rigid muscles, loss of movement, and tremors are all possible symptoms of a stroke in the basal ganglia. The basal ganglia control coordination of movement, and when these nerve centers become damaged, the body loses this ability.[livestrong.com]
  • Changes in body movement: - Rigid, stiff movement - Movement loss - Tremors - Ataxia - Difficulty swallowing - Difficulty in smiling or speaking II. Cognitive impairment: - Ability to make decisions - Memory - Language - Attention III.[slideshare.net]
  • Thalamic Syndrome A group of signs and symptoms including sensory loss, pain, dysesthesia, choreoathetosis, tremor, and hemiparesis occur if thalamogeniculate artery is occluded.[healthfixit.com]
  • It can cause mild tremors in the body and loss of movement. There may be difficulty in swallowing and smiling and even speaking. All these bodily changes are indicative of stroke.[diseasespictures.com]
Chorea
  • Despite its rarity, non-ketotic hyperglycemic chorea-hemiballismus should be included in the differential diagnosis of basal ganglia hyperdensity on CT scan, as it can mimic basal ganglia hemorrhage.[ncbi.nlm.nih.gov]
  • Dystonia, asterixis, chorea and hypokinesia are reported after basal ganglia stroke, but restless leg syndrome (RLG), distinguished by a rather unpleasant sensation in the lower extremity, is particularly associated with basal ganglia hemorrhage.[symptoma.com]
  • Transient Choreoathetosis It comes from the root words “chorea” which is an uncontrollable, rapid movement and “athetosis” meaning twisting and wiggling movement of the hands and feet.[healthfixit.com]
Dystonia
  • Dystonia, asterixis, chorea and hypokinesia are reported after basal ganglia stroke, but restless leg syndrome (RLG), distinguished by a rather unpleasant sensation in the lower extremity, is particularly associated with basal ganglia hemorrhage.[symptoma.com]
  • Certain brain disorders like Huntington’s disease, Parkinson’s disease, Wilson’s disease, multiple system atrophy and dystonia can also cause basal ganglia stroke. In rare cases, severe hypertension and diffused hypoxic injury can cause stroke.[diseasespictures.com]
  • There are certain brain disorders, including Huntington’s disease, Parkinson’s disease, Wilson’s disease, multiple atrophy, and dystonia that can lead to a basal ganglia stroke.[belmarrahealth.com]
Focal Neurologic Deficit
  • The clinical presentation of hemorrhagic lesions in the brain encompasses several nonspecific features - nausea, headache, vomiting and altered mental state, but several authors have described specific focal neurological deficits in the setting of basal[symptoma.com]
  • At the time of discharge, no focal neurological deficit was noted.[asianjns.org]

Workup

The diagnosis of all intracerebral hemorrhages must be as soon as possible. For this reason, physicians must promptly obtain a detailed patient history and conduct a complete physical examination. The appearance of symptoms, their features, the events that preceded their onset (to determine whether the etiology was traumatic or not), as well as assessment of risk factors (hypertension, cigarette smoking, alcohol abuse, the presence of additional comorbidities, eg. kidney or liver disease, malignancy, but also diabetes mellitus), and a history of similar events should be a part of the patient history [1] [9]. Recent use of anticoagulant, antithrombotic or other known drugs that disrupt the homeostasis of the vascular system is also vital in identifying the possible pathogenesis [9], while a complete physical examination, with an emphasis on neurological evaluation, is crucial for determining the site of the lesion. Laboratory testing should be immediately employed, including a complete blood count (CBC), a full coagulation panel, serum electrolytes and renal function [9]. The gold standard for the diagnosis of all intracranial hemorrhages, however, are imaging studies, and computed tomography (CT), widely used as the initial study, is regarded as the optimal procedure, primarily because hemorrhage is evident almost instantaneously after its occurrence [1] [3]. Magnetic resonance imaging (MRI) is an effective procedure as well and is even superior in terms of identification of the underlying pathology (eg. malignancy) [1] [4].

Treatment

  • Conservative treatment achieved a better mean Barthel Index at MICH 0 or 1 than surgical treatment, p .01. At MICH scores 3 or 4, 6-month mortality for conservative treatment was higher than for surgical treatment, p .01 and p .04, respectively.[ncbi.nlm.nih.gov]
  • METHODS: Patients meet the criteria will be randomized into the endoscopic surgery group (endoscopic surgery for hematoma evacuation and the best medical treatment) or the conservative treatment group (the best medical treatment).[ncbi.nlm.nih.gov]
  • […] alone (Group A, n 44) and best medical treatment plus catheterization (Group B, n 49).[ncbi.nlm.nih.gov]
  • Twelve patients with conservative treatment were recruited as control.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The study reveals that depression is a common long-term complication after surgical treatment of hypertensive basal ganglion hemorrhage.[ncbi.nlm.nih.gov]

Prognosis

  • Old age (greater than 60), abnormal pupil reaction, impaired oculocephalic response, and abnormal motor response to pain stimuli are reliable clinical hallmarks for poor prognosis.[ncbi.nlm.nih.gov]
  • CONCLUSION: The clinical features, causes and prognosis were summarized and discussed, in perspective of providing guidance for future diagnosis and treatment.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Neuronavigation-assisted minimally invasive operation is suitable for low volume hypertensive basal ganglia hemorrhage and improves the prognosis of these patients significantly.[ncbi.nlm.nih.gov]
  • Stereotactic aspiration and thrombolysis is a safe and effective way to clear hematomas within short time, thus reducing the neurological impairment from hematoma mass effect and secondary brain injury, improving prognosis.[ncbi.nlm.nih.gov]
  • Patients who suffer from large spontaneous intracerebral hemorrhages (ICH) of the basal ganglia have a very poor prognosis. However, the benefit of surgery for the management of ICH is controversial.[ncbi.nlm.nih.gov]

Etiology

  • A complete laboratory work-up and imaging studies were unremarkable for infectious etiology, new intracranial hemorrhage, and deep vein thrombosis. The patient was diagnosed with sympathetic storming, a relatively uncommon cause of these symptoms.[ncbi.nlm.nih.gov]
  • The appearance of symptoms, their features, the events that preceded their onset (to determine whether the etiology was traumatic or not), as well as assessment of risk factors (hypertension, cigarette smoking, alcohol abuse, the presence of additional[symptoma.com]
  • […] gif 27kB pic source Intracerebral Hemorrha... 475 x 550 jpeg 114kB pic source Basal Ganglia - Anatom... 746 x 462 jpeg 49kB pic source Med Students Lecture S... 960 x 720 jpeg 83kB pic source Deep intracranial hemo... 850 x 582 png 149kB pic source Etiologies[sammlungfotos.online]

Epidemiology

  • The author discusses these advances and updates on the epidemiology and pathophysiology of intracerebral hemorrhage.[medlink.com]
  • MAYORGA-VILLA Journal of Neurosurgical Sciences 2018 February;62(1):46-50 Epidemiology, molecular classification and WHO grading of ependymoma Jens-Martin HÜBNER, Marcel KOOL, Stefan M. PFISTER, Kristian W.[minervamedica.it]
  • 149kB pic source Etiologies of Neurogen... 960 x 720 jpeg 88kB pic source Current management of ... 1800 x 1671 jpeg 263kB pic source Causes of Intracerebra... 590 x 208 jpeg 46kB pic source Medical and Surgical M... 960 x 720 jpeg 78kB pic source PPT - Epidemiology[sammlungfotos.online]
  • Epidemiology and natural history of arteriovenous malformations. Neurosurg Focus 2001;11:e1. 62. Lv X, Liu J, Hu X, Li Y. Patient age, hemorrhage patterns, and outcomes of arteriovenous malformation. World Neurosurg 2015;84:1039-1044. 63.[j-stroke.org]
Sex distribution
Age distribution

Pathophysiology

  • The author discusses these advances and updates on the epidemiology and pathophysiology of intracerebral hemorrhage.[medlink.com]
  • Intracerebral Stress Distribution and Its Effect 103 Evolution of Surgical Treatment of Chronic Subdural Hematomas 110 Development and Treatment of Chronic Subdural Hematoma 117 The Relationship Between Cephalic Index and Chronic Subdural Hematoma 125 Pathophysiological[books.google.com]
  • Pathophysiology If a person suffers from chronic hypertension and this is not properly kept under control, this will lead to a number of pathological changes at the level of the blood vessels (including those at the level of the brain).[hellomrdoctor.com]
  • A small amount of TBGH ( 4) It can be related to diffuse axonal injury when it is associated with contusions and/or small hemorrhage in the corpus callosum, basal ganglia, tegmentum of pons, IVH, and acute brain swelling. 11) The pathophysiologic mechanism[synapse.koreamed.org]
  • Published on Jun 26, 2014 This presentation contains anatomy, pathophysiology, clinical presentation, doctor & physiotherapy management (generally) 1. Stroke: Basal Ganglia Bleed 2.[slideshare.net]

Prevention

  • The outlook following a hemorrhage in this area depends on the size and location of the bleed, but controlling high blood pressure can help prevent some strokes from occurring.[wisegeekhealth.com]
  • Dearden NM (1998) Mechanisms and prevention of secondary brain damage during intensive care. Clin Neuropathol 17(4): 221–228 PubMed Google Scholar 2.[link.springer.com]
  • Treatment and Prognosis In general, one of the main objectives of the treatment is keeping the hypertension under control, in order to prevent the basal ganglia hemorrhage in the future.[hellomrdoctor.com]
  • Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎[books.google.es]
  • Prevention of Stroke Any forms of CVA are dangerous to face. The best way to never experience stroke is prevention. In order to do that, risk factors (as enumerated in the earlier section of this article) to stroke should be eliminated.[healthfixit.com]

References

Article

  1. Aguilar MI, Brott TG. Update in Intracerebral Hemorrhage. The Neurohospitalist. 2011;1(3):148-159.
  2. Bhargava P, Grewal SS, Gupta B, Jain V, Sobti H. Traumatic bilateral basal ganglia hematoma: A report of two cases. Asian J Neurosurg. 2012;7(3):147-150.
  3. Pandey N, Mahapatra A, Singh PK. Bilateral large traumatic hemorrhage of the basal ganglion. Asian J Neurosurg. 2014;9(4):240.
  4. Landi A, Marotta N, Mancarella C, Marruzzo D, Salvati M, Delfini R. Basal ganglia stroke due to mild head trauma in pediatric age - clinical and therapeutic management: a case report and 10 year literature review. Ital J Pediatr. 2011;37:2.
  5. Su CY, Chen HM, Kwan AL, Lin YH, Guo NW. Neuropsychological impairment after hemorrhagic stroke in basal ganglia. Arch Clin Neuropsychol. 2007;22(4):465-474.
  6. Paradiso S, Ostedgaard K, Vaidya J, Ponto LB, Robinson R. Emotional blunting following left basal ganglia stroke: The role of depression and fronto-limbic functional alterations. Psychiatry research. 2013;211(2):148-159.
  7. Park J. Movement Disorders Following Cerebrovascular Lesion in the Basal Ganglia Circuit. Mov Disord. 2016;9(2):71-79.
  8. Lee SJ, Kim JS, Song IU, An JY, Kim YI, Lee KS. Poststroke restless legs syndrome and lesion location: anatomical considerations. Mov Disord. 2009 Jan 15;24(1):77-84.
  9. Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007; 38(6):2001–2023.

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Last updated: 2018-06-21 23:01