Letter to the editor Quadriparesis due to simultaneous occurrence of hemorrhagic and ischemic stroke Dear editor, Although stroke is a common neurological disorder, simultaneous occurrence of hemorrhagic and ischemic stroke has been considered a rarity. Very few cases have been reported in which the causes were attributable to multiple uncontrolled risk factors promoting atherosclerosis. Here we report a patient from Nigeria with simultaneous onset of both hemorrhagic and ischemic stroke and good outcome. A 54-year-old right-handed, obese [body mass index (BMI): 40], postmenopausal woman from Nigeria presented with a five-day history of weakness in all four limbs and slurred speech. She had no history of previous stroke, smoking, or alcohol abuse, but was recently diagnosed with hypertension. She was not on any anticoagulant or antiplatelet therapy. On examination, the blood pressure was 160/ 100 mmHg and the pulse was 88/min and regular. The neurological examination revealed quadriparesis (grade 3 power on the left upper and lower limbs, grade 4 on right upper limb, and grade 3 power on right lower limb on the Medical Research Council rating) and Babinski sign present bilaterally. Routine laboratory investigations showed a normal full blood count. The fasting blood glucose was within the normal range (4·9 mmol/l). Lipid profile was deranged: total cholesterol – 6·0 mmol/l, triglycerides – 5·4 mmol/l, HDL – 1·5 mmol/l, LDL – 4·2 mmol/l. An urgent computed tomography (CT) scan Correspondence: Andreas Charidimou*, Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Box 6, Queen Square, London WC1N 3BG, UK. E-mail: [email protected] Conflict of interest: None declared. DOI: 10.1111/ijs.12404
© 2015 World Stroke Organization
Fig. 1 Brain CT six-days postsymptom onset showing a right-sided internal capsule hemorrhage and a left-sided small infarct of the internal capsule.
revealed bilateral strokes: a right internal capsule hemorrhage and a left small deep infarct in internal capsule (Fig. 1). The patient was successfully managed and recovered with minimal residual deficit. The combination of vascular risk factors might be responsible for the simultaneous occurrence of multiple strokes. Balci et al. reported a simultaneous onset of hemorrhagic and ischemic stroke in a patient with uncontrolled hypertension and atrial fibrillation who died due to brain herniation (1). Simultaneous hemorrhagic and ischemic strokes in different arterial territories were reported in another patient on hemodialysis (2). The presumed cause was a sudden drop of blood pressure and heparin use prior to the hemodialysis. In another report, uncontrolled risk factors for atherosclerosis such as hypertension, hyperlipedemia, and older age were thought to be responsible for the coincidental brainstem ischemic and hemorrhagic stroke that occurred in a 92-year-old male patient (3). In conclusion, simultaneous occurrence of dual stroke, especially both spon-
taneous intracerebral hemorrhage and ischemic stroke, is very rare, but raises clinical dilemmas, e.g., regarding management and antithrombotic drug use. E. E. Philip-Ephraim1, A. Charidimou2*, and G. A. Kajogbola3 1 Neurology Unit, Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria 2 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK 3 Asi Ukpo Diagnostics and Medical Centre, Calabar, Nigeria
References 1 Balci K, Utku U, Asil T, Unlu E. Simultaneous onset of hemorrhagic and ischemic strokes. Neurologist 2007; 13:148–9. 2 Toyoda K, Kumai Y, Fujii K, Ando T, Ibayashi S. Simultaneous onset of haemorrhagic and ischaemic strokes in a haemodialysis patient. J Neurol Neurosurg Psychiatry 2002; 72:673–4. 3 Horozoglu H, Midi I, Afsar N, Aktan S. Coincidental onset of ischemic and hemorrhagic stroke in the brainstem. J Neurol Sci 2010; 27:359–61.
Vol 10, February 2015, E11
E11
Copyright of International Journal of Stroke is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
© 2015 World Stroke Organization
Fig. 1 Brain CT six-days postsymptom onset showing a right-sided internal capsule hemorrhage and a left-sided small infarct of the internal capsule.
revealed bilateral strokes: a right internal capsule hemorrhage and a left small deep infarct in internal capsule (Fig. 1). The patient was successfully managed and recovered with minimal residual deficit. The combination of vascular risk factors might be responsible for the simultaneous occurrence of multiple strokes. Balci et al. reported a simultaneous onset of hemorrhagic and ischemic stroke in a patient with uncontrolled hypertension and atrial fibrillation who died due to brain herniation (1). Simultaneous hemorrhagic and ischemic strokes in different arterial territories were reported in another patient on hemodialysis (2). The presumed cause was a sudden drop of blood pressure and heparin use prior to the hemodialysis. In another report, uncontrolled risk factors for atherosclerosis such as hypertension, hyperlipedemia, and older age were thought to be responsible for the coincidental brainstem ischemic and hemorrhagic stroke that occurred in a 92-year-old male patient (3). In conclusion, simultaneous occurrence of dual stroke, especially both spon-
taneous intracerebral hemorrhage and ischemic stroke, is very rare, but raises clinical dilemmas, e.g., regarding management and antithrombotic drug use. E. E. Philip-Ephraim1, A. Charidimou2*, and G. A. Kajogbola3 1 Neurology Unit, Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria 2 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK 3 Asi Ukpo Diagnostics and Medical Centre, Calabar, Nigeria
References 1 Balci K, Utku U, Asil T, Unlu E. Simultaneous onset of hemorrhagic and ischemic strokes. Neurologist 2007; 13:148–9. 2 Toyoda K, Kumai Y, Fujii K, Ando T, Ibayashi S. Simultaneous onset of haemorrhagic and ischaemic strokes in a haemodialysis patient. J Neurol Neurosurg Psychiatry 2002; 72:673–4. 3 Horozoglu H, Midi I, Afsar N, Aktan S. Coincidental onset of ischemic and hemorrhagic stroke in the brainstem. J Neurol Sci 2010; 27:359–61.
Vol 10, February 2015, E11
E11
Copyright of International Journal of Stroke is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
