Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
LETTER TO EDITOR  
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 149-150
Concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival


Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan

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Date of Submission26-Oct-2017
Date of Acceptance09-Nov-2017
Date of Web Publication29-May-2018
 

How to cite this article:
Iso T, Yanagawa Y, Takeuchi I, Suwa S. Concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival. J Emerg Trauma Shock 2018;11:149-50

How to cite this URL:
Iso T, Yanagawa Y, Takeuchi I, Suwa S. Concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival. J Emerg Trauma Shock [serial online] 2018 [cited 2019 Sep 19];11:149-50. Available from: http://www.onlinejets.org/text.asp?2018/11/2/149/233398




Dear Editor,

We encountered a unique patient with concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival. A 72-year-old woman was found collapsed on the floor in her house. She had diabetes mellitus and hypertension. On arrival, her Glasgow Coma Scale was 13 in total, and she had right hemiplegia and bed sores with infectious signs. Head computed tomography (CT) on arrival demonstrated left old lacunar infarction at the putamen, a left subtle low-density spot in the posterior crus of the internal capsule, and a right high-density area at the head of the caudate nucleus [Figure 1]. Magnetic resonance imaging (MRI) executed immediately after CT revealed a left lesion at the internal capsule that was hyper-intenseon diffusion-weighted imaging. However, MRI showed a right lesion at the head of the caudate nucleus as hypo-intenseon T2*-weighted imaging [Figure 2]. Based on these physical, biochemical, and radiological findings, she was diagnosed with an acute cerebral infraction, remote concomitant intra-cerebral hemorrhaging, hyperglycemia, renal failure with hyperkalemia, dehydration, and infection of bedsores. After admission, her general condition improved gradually by intensive care, and she regained consciousness and fed herself using her left hand. Her right upper extremity showed no change, but she was able to move her right lower extremity slightly. She was transferred to another hospital for rehabilitation.
Figure 1: Head computed tomography on arrival. Computed tomography demonstrated left old lacunar infarction at the putamen, a left subtle low-density spot in the posterior crus of the internal capsule, and a right high-density area at the head of the caudate nucleus

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Figure 2: Magnetic resonance image on arrival. The magnetic resonance image revealed a left lesion at the internal capsule (arrow) that was hyper-intense on diffusion-weighted imaging and ahypo-intense area on the apparent diffusion coefficient map (middle). However, magnetic resonance image showed a right lesion at the head of the caudate nucleus (triangle) as hypo-intense on T2*-weighted imaging (right)

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To the best of our knowledge, this is the first report of concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival. Regarding why this concomitance occurred, at the microscopic level, disseminated intravascular coagulation (DIC) can produce such concomitance.[1] However, the present patient did not meet the DIC criteria. A previous report described a case of infarction complicated15 days after acute intra-ventricular bleeding due to moyamoya disease.[2] Dehydration and hypotension were suspected as potential contributing factors of progressive injury. However, our patient did not have moyamoya disease. Which of the two lesions occurred first could not be determined, but the simultaneous occurrence of both was likely impossible. Stroke has been shown to evoke reactive hypertension due to an increase in vascular resistance or intracranial hypertension.[3],[4] If an ischemic stroke occurs first, reactive hypertension may promote remote intra-cerebral hemorrhaging. However, Kim and Kimreported the development of cerebral infarction shortly after intra-cerebral hemorrhaging.[5] They suspected the mechanism to involve the mechanical compression of cerebral vessels, hemodynamic instability, inflammation, and/or concomitant small-vessel pathology. As our patient had dehydration and infection, these complications might have induced cerebral infarction if the hemorrhagic stroke occurred first.

Acknowledgment

This manuscript received financial support from the Ministry of Education, Culture, Sports, Science and Technology (MEXT)-Supported Program for the Strategic Research Foundation at Private Universities, 2015–2019 concerning (The constitution of a total researchsystem for comprehensive disaster and medical management, corresponding to wide-scale disasters).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This manuscript received financial support from the Ministry of Education, Culture, Sports, Science and Technology (MEXT)-Supported Program for the Strategic Research Foundation at Private Universities, 2015–2019 concerning (The constitution of total researching system for comprehensive disaster, medical management, corresponding to wide-scale disaster).

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Schwartzman RJ, Hill JB. Neurologic complications of disseminated intravascular coagulation. Neurology 1982;32:791-7.  Back to cited text no. 1
    
2.
Su IC, Yang CC, Wang WH, Lee JE, Tu YK, Wang KC. Acute cerebral ischemia following intraventricular hemorrhage in moyamoya disease: Early perfusion computed tomography findings. J Neurosurg 2008;109:1049-51.  Back to cited text no. 2
    
3.
Asakura K, Mizuno M, Yasui N. Clinical analysis of 24 cases of caudate hemorrhage. Neurol Med Chir (Tokyo) 1989;29:1107-12.  Back to cited text no. 3
    
4.
Shiomi N, Miyagi T, Koga S, Karukaya T, Tokutomi T, Shigemori M. Simultaneous multiple hypertensive intracerebral hematoma. No Shinkei Geka 2004;32:237-44.  Back to cited text no. 4
    
5.
Kim CH, Kim JS. Development of cerebral infarction shortly after intracerebral hemorrhage. Eur Neurol 2007;57:145-9.  Back to cited text no. 5
    

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Correspondence Address:
Takashi Iso
Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_118_17

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