Basal Ganglionic Haematoma Simulating Transient Ischaemic Attack

An elderly hypertensive presented with a sudden onset hemiparesis recovering within 30 minutes. CT scan of the brain revealed a small basal ganglionic haematoma.

INTRODUCTION

Transient ischaemic attack (TIA) is defined as an acute onset reversible focal neurological deficit resulting from vascular disease which recover completely in 24 hours. Most TIAs rarely last more than 30 minutes. TIAs are most commonly due to atherothromboembolic brain disease. Rare causes of TIAs include intracranial tumours, chronic subdural haematomas and unruptured giant AV malformations. Intracerebral haematomas generally present as major and minor strokes. TIA like presentation of intracerebral haematoma is very rare. We report a case of TIA caused by a small basal ganglionic haematoma.

CASE REPORT

A 55 year old, right handed male, known hypertensive, non diabetic, while driving a vehicle suddenly noticed weakness of left side of body, with slight slurring of speech. He had stopped antihypertensive treatment since two weeks. On examination, he was found to have left sided hemiparesis. His blood pressure was 220/120 mm of Hg. He started recovering in 15-20 minutes and by 30 minutes showed significant recovery. A CT scan of brain performed on the same day showed a small right sided basal ganglia haematoma with surrounding oedema. His review examination on the next day revealed no subjective or objective neurological deficit. Other investigations including CBC, ESR, ECG, Lipid, coagulation and bleeding profile were normal, 2D echo of heart showed mild concentric LVH. The anticardiolipin antibody was negative. MR angio and MR venography were normal. Patient was discharged after one week on Antihypertensive treatment. On regular follow up he has no neurological deficit.

Fig 1: CT scan of head showing small basal ganglionic haematoma.

DISCUSSION

Clinical presentation of intracerebral haematomas is usually major and minor strokes. It is very rare for them to present as TIA. The mechanisms whereby brain haemorrhage can present as TIA are largely unknown but could be due to impairment of regional cerebral blood flow[1] or very rarely secondary to a steal phenomenon associated with an arteriovenous malformation.[2]

A significant contributory factor for TIA to occur is any condition which predisposes to impairment of regional cerebral blood flow (rCBF).[3] Although TIA leaves the patient without clinical evidence of neurological deficit, abnormalities in rCBF persist for 1-4 days[4] and sometimes upto 90 days.[5] The abnormalities in rCBF, caused by putaminal haematomas may persist upto 4-5 months.

In our patient disturbance of rCBF caused by basal ganglia haematoma might have been responsible for TIA and slightly delayed recovery could be due to longer persistence of changes in rCBF in haematoma. This case illustrates necessity of doing CT scan of brain in every case of TIA before starting antiplatelet drug as it may be rarely caused by chronic subdural haematomas, unruptured intracranial aneurysms and small intracerebral haematomas.

REFERENCES

1. Tsuda Y, Ayada Y, et al. Semiquantitative regional CBF evaluation using I123 IMP SPECT in a case showing transient ischaemic attack caused by putaminal haemorrhage. Acta Neurol Scand 1991; 84 : 448-51.

2. Mast H, Mohr JP, Osipov A, et al. Steal is an unestablished mechanism for the clinical presentation of cerebral arteriovenous malformations. Stroke 1995; 26 : 1215-20.

3.Panagariya A, Maru A, Sharma B. Transient Ischaemic Attack caused by a small basal ganglia haematoma. J Assoc Physicians India 1999; 47 : 935.

4. Skinhoje, Hoedt Pusmussen K, Paulson OB, Lassen NA. Regional cerebral blood flow and its autoregulation in patients with transient focal cerebral ischaemic attacks. Neurology 1970; 20 : 485-93.

5..Ress JE, Bull JWD, Ross Russel RW, Bu Biolay GH, Marshall J, Symonal. Regional cerebral blood flow in transient ischaemic attacks. Lancet 1970; 2 : 1210-3.