ANALELE UNIVERSITĂȚII DUNĂREA DE JOS GALAȚI [613419]

ANALELE UNIVERSITĂȚII “DUNĂREA DE JOS” GALAȚI
MEDICINĂ
FASCICULA XVII, no 2, 2012

21 CASE REPORT
RECOMBINANT ACTIVATED FACTOR VII FOR
BILATERAL SPONTANEOUS BASAL GANGLIA HAEMORRHAGE
WITH TETRAVENTRICULAR EXTENSION -CASE REPORT

C. C. Stancu1 , R. Diaconescu2

1 Emergency County Hospital, Slatina, Romania
2 University of Medicine and Pharmac y, Craiova , Romania

[anonimizat]

ABSTRACT

Bilateral spontaneous basal ganglia haemorrhages with intraventricular extension are rare cases in
clinical practice. We report one such case of a 65 -year-old woman with a history of untreated hyperte nsion and
mixed dyslipidemia brought to the emergency room by her family within one hour after symptoms onset. The
non-contrast brain computed tomo -graphy (CT) scan revealed bilateral basal ganglia haemorrhage with
tetraventricular exten -sion. The patient received a single dose of recombinant activated factor VII (rFVIIa) 20
μ/kg. and repeated CT scans were used to monitor the brain lesions. By the time she was discharged, patient
experienced almost a complete remission of her neurological symptoms and reso rption of the bleeding.

KEYWORDS : Bilateral spontaneous basal ganglia haemorrhage, tetraventricular extension, recombinant
activated factor VII

1. Introduction

Bilateral spontaneous basal ganglia
haemorrhages with intraventricular extension are rare
cases in clinical practice, generally a ssociated with a
poor outcome. [1]
The particularity of this case lies not only in
the bleeding topography. It is also one of the cases
receiving one -shot therapy with rFVIIa during
hyperacute stage of intracerebral h emorrhage.
It is now recognized that almost a third of
patients have significant expansion of their
hemorrhage in the first few hours after presentation.

[2] rFVIIa significantly reduce intracerebral
hemorrhage (ICH) expansion when given within first
few hours of onset and impr ove patients survival
outcome. [3]

2. Case report

A 65 -year-old women was brought to the
emergency room by her family within one hour of
onset severe headache, vomiting and mild left sided
weakness triggered by an emotional confl ict. The
patient had a long history of untreated hypertension
and mixed dyslipidemia. Family denied any history of

ANALELE UNIVERSIT ĂȚII “DUNĂREA DE JOS ” GALAȚI FASCICULA XVII

22 trauma or toxic abuse. Physical exam revealed a
blood pressure of 195/100mmH and a pulse of 86/’.
Laboratory test results have shown
hypercho lesterolemia (cholesterol 316mg/dl),
hypertriglyceridemia (triglyceride 219mg/dl) and
hyperglycemia (blood glucose 183mg/dl). Other
laboratory tests (complete blood count, coagulation
tests, serum electrolytes, liver and kidney function
tests) were in the normal ranges.
Non-contrast CT scan of the brain performed
on hospital admission showed: intraparenchymal
hematoma involving the right basal ganglia (34/25
mm in size) with mass effect upon the ventricular
system, a small haemorrhage (10/6 mm in size) of t he
left basal ganglia and tetraventricular extension
(Figure 1).
A diagnosis of bilateral spontaneous basal
ganglia haemorrhage with tetraventricular extension
was made.

Figure 1. Images of non -contrast CT brain performed
on ad mission

Figure 2. Images of non -contrast CT brain performed
5 days later

Figure 3 . Images of non -contrast CT brain performed
15 days later
The patient received a singleshot of rFVIIa 20
μ/kg. High blood pressure and hyperglycemia were
properly treated.
Patient was followed up and monitored
throughout her clinical course and repeat CT scans 5
and 1 5 days later were analysed (Figures 2 and 3).
On the second day of hospitalization, patient’s
menta l status improved revealing her anterograde
amnesia during the 48 hours elapsed since the
symptoms onset and recent bilateral hypoacusis,
subsequently confirmed by audiometric measures.
Patient had no history of ear disease.
She had an extremely favorable clinical course
with almost complete remission of her neurological
symptoms and resorption of the bleeding.
After 15 days, patient was discharged from the
hospital with no evident motor deficit but with
persistence of anterograde amnesia and bilateral
hypo acusis.
Today, almost 2 years after her hospital
discharge, the patient visit us regularly and is in a
very good post -stroke health.

3. Discussions

Bilateral spontaneous basal ganglia
haemorrhages with intraventricular extension are rare
cases in clinic al practice. (1) Elevated blood pressure
is found in over 90% of patients acutely, even if there
is not a prior history of hypertension. [4]
Typical features found in many patients
include focal neurologic signs, headache, nausea,
vomiting and alterations in the level of consciousness.
[5] Rare bilateral putaminal haemorrhages have been
reported to cause cortical deafness or amnesia. [6.7]
Prognosis depends upon a variety of factors:
age, degree of impairment of consciousness,
topographic localization and volume of haemorrhage,
intraventri cular extension. [5,8,9]

ANALELE UNIVERSIT ĂȚII “DUNĂREA DE JOS ” GALAȚI FASCICULA XVII

23 Among modifiable factors, hematoma
expansio n may have a predominant role. [10]
„Spot Sign” is a biomarker defined by contrast
extravasation on CT angiography (CTA). A recent
prospective, internatio nal study, validating the utility
of the „spot sign” for hematoma growth, supports the
continued investigation of „spot sign’ stratificat ion
for haemostatic treatment. [11 -13]
So far there is no specific drug therapy for
brain haemorrhage, but there are numerous ongoing
clinical trials to evaluate efficacy of rFVIIa in the
early stages of bleeding. [3,13]
Ultra -early rFVIIa, within the first few hours
of ICH onset has been shown to significantly reduce
neurological deterioration. This can be achieved by
limiting the extent of the hematom a and rebleeding
prophylaxis. [3]
Proper selection of patients at high risk for
haematoma expansion seems crucial to improve
outcomes. Rigorous scientific investigation in clinical
trials should bring additional informatio n about "spot
sign" as a target for selecting patients for
rFVIIa.[12,13]

4. Conclusions

Bilateral spontaneous basal ganglia
haemorrhages with intraventricular extension are rare
cases in clinical practice and are associated with a
poor prognosis.
Singl e-shot therapy with rFVIIa during
hyperacute stage of intracerebral hemorrhage. was
followed by improvement of clinical course.
We have a modest experience with only 40
cases with intracerebral haemorrhage treated with
rFVIIa.
Even though he generated much controversy
over time, we strongly believe that rFVIIa is not
history for the management of brain haemorrhage in
non-hemophilia patients. If tissue plasminogen activator (rtPA) proved
to be a"cost -effective" strategy for the management of
acute ischemic s troke according to standard selection
criteria, despite its high cost and increased incidence
of haemorrhagic side effect, we believe that rFVIIa
could play its role in the brain haemorrhage
treatment.
Scientific investigation in clinical trials should
bring additional information that could lead to
development of a algorithm stratification for this type
of therapy.

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