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Recurrent, sequential, bilateral deep cerebellar hemorrhages: a case report
© Amin et al; licensee BioMed Central Ltd. 2011
Received: 29 January 2011
Accepted: 10 August 2011
Published: 10 August 2011
Hypertensive intra-cerebral hemorrhage is usually a one-time event and recurrences are rare. Most recurrences develop as part of long-term failure of blood pressure control. The site of the re-bleed is usually limited to the basal ganglia and thalami.
We report the case of a 59-year-old hypertensive Caucasian woman who developed two sequential, right- and then left-sided, deep cerebellar hemorrhages. The second hemorrhage followed the first one by 57 days, at a time when her blood pressure was optimally controlled. In spite of these critical sites and short duration between the two bleeds, the patient achieved a relatively good functional recovery. Her brain magnetic resonance angiogram was unremarkable.
The development of recurrent hypertensive hemorrhage is rare and usually occurs within two years of the first bleed. To the best of our knowledge, this is the first reported case of bilateral, sequential, right- and then left-sided deep cerebellar hemorrhages. These hemorrhages were separated by eight weeks and the patient had a relatively good functional recovery. We believe that hypertension was the etiology behind these hemorrhages.
Hypertensive intra-cerebral hemorrhage is usually a one-time event and recurrences are rare. Most of these recurrences develop as part of a failure of blood pressure control and within two years of the first hemorrhage. The sites of the re-bleed are usually limited to the basal ganglia and thalami.
Mohr et al.  analyzed 694 hospitalized stroke patients and found that intra-cerebral hemorrhage (ICH) is the third most common cause of stroke; embolic ischemic stroke and atherothrombotic infarction ranked second and first on that list of frequency, respectively. ICH constitutes 10% to 15% of all stroke subtypes .
Long-standing arterial hypertension is responsible for about 50% of all cases of primary ICH , and according to Thrift and colleagues  this hypertension doubles the risk of developing ICH. The necrotizing effect of long-standing hypertension on the wall of small penetrating blood vessels (<300 μm in diameter) leads to the formation of Charcot-Bouchard micro-aneurysms; rupture of the latter leads to intra-parenchymal hemorrhage . Approximately 20% of hypertensive hemorrhages develop in the posterior fossa; the rest are supratentorially located. In the cerebellum, the small penetrating branches of superior cerebellar arteries (and posterior inferior cerebellar arteries to a lesser extent) on either side are the usual target for micro-aneurysmal formation [6–8]. Therefore, most hemorrhages appear in the region of the dentate nuclei. These cerebellar hemorrhages account for approximately 5% to 15% of all primary ICHs [9–12]; the cerebellum is the fourth most common site for spontaneous ICHs, trailing thalamic, lobar, and putamenal hemorrhages .
In 1984, Kunitz and coworkers  respectively analyzed the NINCDS Stroke Data Bank. Only one out of 101 patients with hemorrhagic strokes had a history of intra-cerebral hemorrhage. Therefore, primary spontaneous ICH can be considered a one-time event. Douglas and Haerer  found that hypertensive intra-cerebral hemorrhages, unlike Berry's aneurysms, rarely, if ever, re-bleed at the same site. On the other hand, patients are not likely to have a second bleed in another location. According to Gonzalez-Duarte and colleagues , recurrent hypertensive intra-cerebral hemorrhages do occur, but at a very low rate, and the main topographic pattern of re-bleeding is basal ganglionic-ganglionic. Non-hypertensive recurrent hemorrhages tend to be lobar in location, in contrast to the hypertensive ones. Bae and associates  concluded that the recurrence rate is 5.4% and that most recurrences develop within two years of the first hemorrhage. They also found that all of these re-bleedings occurred at sites different from the first ones, but the majority were within the basal ganglia and thalami and all were related to poor arterial blood pressure control.
The short-term mortality of recurrent hypertensive hemorrhages is considerably higher (32%)  than that of the first hemorrhages (20%) . As for the long term functional outcome, Portenoy et al.  found that 55% of patients achieve a good functional recovery after sustaining a hypertensive ICH, a figure that falls to 23% if a recurrence develops .
Our patient developed a right-sided deep cerebellar hemorrhage; the subsequent eight weeks were marked by a good functional recovery and optimal blood pressure control. Another hemorrhage at the left dentate nuclei occurred after 57 days and resolved in a relatively favorable functional independence. Conventional cerebral angiography was not done because of the lack of expertise in our hospital's radiology department. Brain MRA after two weeks revealed no vascular anomaly.
Although hypertension is the most common etiology behind the development of non-traumatic intra-cerebral hemorrhage in adults [3, 20, 21], the occurrence of recurrent hemorrhages should always prompt the physician to search for an underlying cause(s), such as multiple ischemic strokes with secondary hemorrhagic transformation, reperfusion after thrombolytic therapy, extension from a subarachnoid bleed, vascular anomalies, tumors, congophilic angiopathy, blood dyscrasias, vasculitis, coagulopathy, and illicit drug use [22–27]. Our patient's clinical features, examination, and work-up have excluded the risk factors listed above.
The development of recurrent hypertensive hemorrhage is rare and usually occurs within two years of the first bleed. To the best of our knowledge, this is the first reported case of bilateral, sequential, right- and then left-sided, deep cerebellar hemorrhage. The hemorrhages occurred eight weeks apart and she had a relatively good functional recovery. We believe these hemorrhages were hypertensive in etiology.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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