Concomitance Acute Cerebral Infarction and Remote Intra-Cerebral Hemorrhaging on Arrival.

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

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)

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.[34] 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.

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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.