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Annals of Indian Academy of Neurology
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CASE REPORT
Year : 2006  |  Volume : 9  |  Issue : 2  |  Page : 122-123
 

Putaminal haemorrhage: An unusual imaging picture


Department of Neurology, King George Medical University, Lucknow - 226003, India

Correspondence Address:
Ravindra Kumar Garg
Department of Neurology, King George Medical University, Lucknow - 226003,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.25987

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  Abstract 

CT scan images may show fluid level in cerebral hemorrhage secondary to anticoagulation, thrombolytic therapy or with amyloid angiopathy. Other causes of fluid levels are cerebral hemorrhage with underlying malignancy, cerebral arteriovenous malformations or radiation. We are reporting a putaminal hemorrhage with fluid level in a patient with high blood pressure. This case was unusual in the absence of any of these factors and rare location in the putamen.


Keywords: Fluid level, layering, putaminal hemorrhage


How to cite this article:
Vinod P, Garg RK, Singh MK, Kar AM. Putaminal haemorrhage: An unusual imaging picture. Ann Indian Acad Neurol 2006;9:122-3

How to cite this URL:
Vinod P, Garg RK, Singh MK, Kar AM. Putaminal haemorrhage: An unusual imaging picture. Ann Indian Acad Neurol [serial online] 2006 [cited 2020 Aug 9];9:122-3. Available from: http://www.annalsofian.org/text.asp?2006/9/2/122/25987



  Introduction Top


Fluid-blood level is defined as a horizontal interface between hypodense serum layered above hyperdense settled blood. Blood fluid level is commonly seen in intra-cerebral haematoma secondary to anticoagulants, or thrombolytic therapy. In elderly, fluid level has also been described with spontaneous lobar haemorrhage, secondary to cerebral amyloid angiopathy.[1],[2],[3] We are reporting a patient of putaminal haemorrhage with a fluid-blood level.


  Case Report Top


A 72-year-old man was admitted with history of sudden onset weakness of left side of body and speech difficulty of 3 days duration, along with unconsciousness of 2 days duration. There was no preceding headache or vomiting. There was no history of heart disease, anticoagulant or antiplatelet drug intake, recent surgery, and bleeding diatheses in the past. A high blood pressure was not recorded in past. Six months back, he underwent an uneventful prostate surgery. General physical examination showed pulse rate of 96 / minute, and blood pressure 190/100 mm Hg on admission. Nervous system examination revealed a comatose state with Glasgow Coma Scale E2 M5 V1. Pupils were normal in size and reaction. Fundus was normal. Cranial nerve examination revealed left supranuclear facial palsy. Motor system examination revealed spasticity, and power of 1/5 in left upper and lower limbs. Deep tendon jerks were brisker on left side. An extensor plantar response was present on the same side. Cardiovascular and respiratory examinations were normal. Blood parameters showed hemoglobin - 13 gm%, total leukocyte count-'8600'/'cu' mm, polymorphs - 78, lymphocytes - 20, and eosinophils - 02. Platelet count was '140000'/'cu' mm. Bleeding time, clotting time, and prothrombin time all were normal. Other tests to detect any coagulopathy were not performed. Biochemistry revealed sodium - 135 mmol/liter, potassium - 4.0 mmol/liter, urea - 78 mg/dl, creatinine - 2.8 mg/dl, and blood sugar - 90 mg/dl. Electrocardiogram was also normal. The patient was immediately subjected to CT scan of brain, which revealed a large right putaminal haematoma. The volume of haematoma was approximately 50 ml. There was compression of right lateral ventricle along with significant mass effect. Haematoma also showed a blood fluid level [Figure - 1]. The patient was managed in intensive care unit. The patient demonstrated no improvement, and died after two days of hospital stay. The cause of death was raised intracranial pressure.


  Discussion Top


The presence of intracranial hemorrhage with a fluid-blood level in patients receiving anticoagulants or with coagulopathy, is an infrequent but well-documented complication. Our case is unusual, because firstly, we could not demonstrate any coagulopathy, and secondly this fluid level was seen in a large putaminal bleed. Blood fluid represents interface between unclotted serum (hypodense) and sedimented red cells (hyperdense). An autopsy study demonstrated that the sharply demarcated interface represents a boundary between plasma and sedimented blood.[4] In earlier reports, it was suggested that blood-fluid levels seen on cerebral CT were indicative of preexisting tumor or arteriovenous malformations. Later, several other mechanisms like radiation-induced necrosis, cerebral amyloid angiopathy, or a haematoma in the infarct were suggested.[5],[6] At present, coagulopathies and thrombolytic therapy are the commonest conditions where blood fluid level in an intracranial haematoma has been demonstrated.[2],[7] The prevalence of fluid-blood levels in acute intracerebral haemorrhages was determined by computed tomography in 32 patients with elevated prothrombin time or partial thromboplastin time. This was compared with the frequency of fluid-blood levels in 185 patients with intracerebral haemorrhage, in which there was no laboratory evidence of coagulopathy. The probability of finding a fluid-blood level in a patient with a demonstrable coagulopathy was 59%. The probability that there will be no fluid-blood level in a patient without a coagulopathy, was found to be 98%.[3] In another series, after observing CT findings of intracerebral haemorrhage in patients undergoing thrombolytic therapy for acute myocardial infarction, authors noted that out of total of 302 patients, there were a total of 22 haemorrhages, and among 11 patients with intraparenchymal haemorrhage, in five patients, there was a fluid-blood level.[7] It is difficult to explain the precise reason of fluid-blood level in our case. In our case, we could not perform certain specific tests to detect coagulopathies like partial thromboplastin time and fibrinogen levels. Since coagulation defects have not been comprehensively excluded, it is likely that rebleeding is the cause for blood fluid level as well as clinical deterioration in this case.[8] Arjona et al had described a similar case. They suggested that in their patient blood fluid level was due to an intrainfarct haematoma.[9]


  Conclusion Top


Blood fluid level is a usual imaging abnormality in patients with intracerebral haematomas, secondary to anticoagulant therapy. We are reporting a case of large putaminal haemorrhage showing blood fluid level. The patient did not have any apparent coagulopathy.

 
  References Top

1.Hinojosa AQ, Gulati M, Singh V, Lawton MT. Spontaneous intracranial haemorrhage due to coagulation disorders. Neurosurg Focus 2003;15:1-17.  Back to cited text no. 1    
2.Warlow CP, Dennis MS, Gijn JV, et al . In : Stroke: A practical guide to management, Barnett HM, 2nd ed. Alden Press: Great Britain; 2001. p. 160-4.  Back to cited text no. 2    
3.Pfleger MJ, Hardee EP, Contant CF Jr, Hayman LA. Sensitivity and specificity of fluid-blood levels for coagulopathy in acute intracerebral hematomas. AJNR Am J Neuroradiol 1994;15:217-23.  Back to cited text no. 3  [PUBMED]  
4.Ichikawa K, Yanagihara C. Sedimentation level in acute intracerebral hematoma in a patient receiving anticoagulation therapy: An autopsy study. Neuroradiology 1998;40:380-2.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Spiegel S, Just N, Goldenberg M. Nonspecificity of intraparenchymal blood-fluid levels in cerebral computed tomography. J Comput Assist Tomogr 1984;8:656-7.  Back to cited text no. 5  [PUBMED]  
6.Zilkha A. Intraparenchymal fluid-blood level: A CT sign of recent intracerebral hemorrhage. J Comput Assist Tomogr 1983;7:301-5.   Back to cited text no. 6  [PUBMED]  
7.Brancatelli G, Sparacia G, Banco A, Barbiera F, Midiri M, La Gattuta F, et al . Thrombolytic therapy in myocardial infarction. Computerized tomography of encephalic complications. Radiol Med (Torino) 2001;101:376-81.   Back to cited text no. 7    
8.Kelley RE, Berger JR, Scheinberg P, Stokes N. Active bleeding in hypertensive intracerebral hemorrhage: computed tomography. Neurology 1982;32:852-6.   Back to cited text no. 8  [PUBMED]  
9.Arjona A, Moreno P, Corral F, Zabala JA, Ricart C. Intracranial hemorrhage with fluid level. A case report without coagulation alterations. Neurologia 1998;13:195-8.   Back to cited text no. 9  [PUBMED]  


    Figures

[Figure - 1]



 

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   Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
   References
   Article Figures

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