====== Primary tectal mesencephalic hemorrhage ======

//J.Sales-Llopis//

//Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and
Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain.//
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see also [[Midbrain hemorrhage]].

Spontaneous [[mesencephalic hemorrhage]]s are very unusual, specially those located in the [[tectum]]. [[Hypertension]] is a less important factor that in other classical locations. Other etiologies reported are [[arteriovenous malformation]]s, [[coagulation disorder]] and [[trauma]]
((Pego R, Martínez-Vázquez F, Brañas F, Ibáñez-Alonso D, Cortés-Laiño JA. Hemorragia espontánea en la lámina cuadrigémina: presentación de dos casos [Spontaneous hemorrhage of the quadrigeminal plate: description of two cases]. Rev Neurol. 1997 Sep;25(145):1414-6. Spanish. PMID: 9377302.)).

{{::primary_tectal_mesencephalic_hemorrhagect.jpg?195|}}
{{::primary_tectal_mesencephalic_hemorrhagemri.jpg?200|}}

===== Case reports =====

Chen et al. reported a 40-year-old normotensive man suddenly developed [[diplopia]], [[tinnitus]] and a [[burning sensation]] on the left side of his body while driving a motorcycle. He did not complain of headache, nausea or vomiting. Neurologic examination revealed left [[trochlear nerve palsy]] and impaired pinprick, temperature and joint position sensation of the left limbs. There was no [[ptosis]] or motor deficit. He had a mild bleeding diathesis due to alcoholic [[liver cirrhosis]]. Computerized tomography and magnetic resonance image of the brain disclosed hemorrhages in the right midbrain [[tectum]] and the left temporal lobe. After nine months of observation, there was nearly complete recovery of symptoms, except for mild residual diplopia. From a literature review, only nine case of midbrain tectal hemorrhage involving the [[inferior colliculus]] have been reported. These patients had a unique clinical presentation. Diplopia due to trochlear nerve palsy, either unilateral or bilateral, was present in all of the cases. Tinnitus and sensory disturbance contralateral to the lesion side were very common. Only three patients had risk factors for hemorrhage, including bleeding diathesis, hypertension and vascular anomalies. In the majority of patients, no underlying causes were detected. The outcome was favorable with conservative treatment
((Chen CH, Hwang WJ, Tsai TT, Lai ML. [[Midbrain hemorrhage]] presenting with [[trochlear nerve palsy]]. Zhonghua Yi Xue Za Zhi (Taipei). 2000 Feb;63(2):138-43. PMID: 10677925.)).
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Kaku et al. reported a [[Transcollicular approach]] for three hematomas who were completely removed, along with abnormal blood vessels in the wall of the hematoma cavity; all three of these patients experienced neurological improvement.
((Kaku Y, Yonekawa Y, Taub E. [[Transcollicular approach]] to intrinsic [[tectal lesion]]s. Neurosurgery. 1999 Feb;44(2):338-43; discussion 343-4. doi: 10.1097/00006123-199902000-00052. PMID: 9932887.)).
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Pego et al. reported 2 cases:

Case 1: a non-hypertensive 30 year-old man who suddenly presented headache, nausea, diplopia and left hemisensory deficit. Twenty-four hours later he lost consciousness but was again alert within five hours. Examination revealed upward and downward gaze palsy and limited convergence. The patient recovered completely within six weeks. 

Case 2: a 38 year-old man without hypertension, who suddenly developed dizziness, occipital headache, nausea and diplopia. On examination, there was impaired upward and downward gaze, limitation of convergence and right arm hyposthesia. After eight weeks examination showed a mild limitation of upward voluntary gaze. CT and MR imaging studies revealed a small quadrigeminal hemorrhage in both cases
((Pego R, Martínez-Vázquez F, Brañas F, Ibáñez-Alonso D, Cortés-Laiño JA. Hemorragia espontánea en la lámina cuadrigémina: presentación de dos casos [Spontaneous hemorrhage of the quadrigeminal plate: description of two cases]. Rev Neurol. 1997 Sep;25(145):1414-6. Spanish. PMID: 9377302.)).
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[[Primary tectal mesencephalic hemorrhage]] with isolated [[trochlear nerve palsy]]
((Kamei T, Uchiyama F, Fukuyama J. [[Primary tectal mesencephalic hemorrhage]] with isolated [[trochlear nerve palsy]]. A case report]. Rinsho Shinkeigaku. 1987 Sep;27(9):1167-9. Japanese. PMID: 3440362.)).

===== References =====