====== Thalamic hemorrhage ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1rswI4Lv9k94Z-iZ1sULHPDTxSsEr-zpK414WRXzKK1YDCzorR/?limit=15&utm_campaign=pubmed-2&fc=20230118021133}} ---- ---- Hemorrhagic bleeding into the [[thalamus]], typically resulting from [[hypertension]]. see also [[Thalamo-mesencephalic hemorrhage]]. see also [[Thalamic stroke]]. ===== Classification ===== Teramoto et al. classified thalamic hemorrhage was classified into 4 types: anterior type (supplied mainly by the tuberothalamic artery), medial (mainly paramedian thalamic-subthalamic artery), lateral (mainly thalamogeniculate artery), and posterior (mainly posterior choroidal artery). The baseline characteristics, complications, and functional outcomes were assessed. ((Teramoto S, Yamamoto T, Nakao Y, Watanabe M. Novel Anatomic Classification of Spontaneous Thalamic Hemorrhage Classified by Vascular Territory of Thalamus. World Neurosurg. 2017 Aug;104:452-458. doi: 10.1016/j.wneu.2017.05.059. Epub 2017 May 19. PMID: 28532917.)). ---- Chung et al. classified [[thalamic hemorrhage]] into four regional types and one global type according to the primary bleeding sites: (i) anterior type occurring in the territory of the [[tuberothalamic artery]], (ii) posteromedial type occurring in the territory of the thalamic-subthalamic paramedian arteries, (iii) posterolateral type occurring in the territory of the [[thalamogeniculate artery]]. (iv) dorsal type occurring in the territory of the [[posterior choroidal artery]] and (v) global type occupying the entire area of the [[thalamus]] ((Chung CS, Caplan LR, Han W, Pessin MS, Lee KH, Kim JM. Thalamic haemorrhage. Brain. 1996 Dec;119 ( Pt 6):1873-86. doi: 10.1093/brain/119.6.1873. PMID: 9009994.)). ===== Etiology ===== [[Hypertension]] was the most frequent cause of thalamic hemorrhage (74%) ((Kumral E, Kocaer T, Ertübey NO, Kumral K. Thalamic hemorrhage. A prospective study of 100 patients. Stroke. 1995 Jun;26(6):964-70. doi: 10.1161/01.str.26.6.964. PMID: 7762047.)), and this result was similar to previous studies that indicated that hypertension was the major risk factor for [[intracerebral hemorrhage]] ((Furlan AJ, Whisnant JP, Elveback LR. The decreasing incidence of primary intracerebral hemorrhage: a population study. Ann Neurol. 1979 Apr;5(4):367-73. doi: 10.1002/ana.410050410. PMID: 375807.)). ===== Clinical features ===== Classically, contralateral hemi[[sensory loss]]. Also [[hemiparesis]] when the [[internal capsule]] is involved. Extension into upper [[brainstem]] → [[vertical gaze palsy]], retraction [[nystagmus]], [[skew deviation]], loss of convergence, [[ptosis]], [[miosis]], [[anisocoria]], ± unreactive pupils. H/A in 20–40%. Motor deficit similar to [[putaminal hemorrhage]], but contralateral [[sensory deficit]] widespread and striking. [[Hydrocephalus]] may occur from compression of CSF pathways. In 41 patients, when hemorrhage > 3.3cm on CT, all died. Smaller hematomas usually caused permanent disability. ---- Medial [[thalamic hemorrhage]]. Wrong-way gaze: Eyes look away from lesion and towards [[hemiparesis]] (an exception to the axiom that the eyes look towards a destructive [[supratentorial]] [[lesion]]) ((Fisher CM. Some Neuro-Ophthalmological Observations. J Neurol Neurosurg Psychiatry. 1967; 30:383–392)). ===== Diagnosis ===== Thalamic hemorrhage is easily recognisable on CT as hyperdensity within the [[thalamus]]. {{::thalamic_hemorrhage.jpg?200|}}{{::thalamic_hemorrhage1.jpg?261|}} see [[Intracerebral hemorrhage diagnosis]] ===== Treatment ===== The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the [[ventricular system]] with [[alteplase]] improved [[functional outcome]]s in patients with small [[intracerebral hemorrhage]] (ICH) and large [[intraventricular hemorrhage]] (IVH). ---- Data suggest that the ultrarapid MIS technique is a safe and effective way in the management of selected cases with thalamic hemorrhage, with favorable long-term functional outcomes. However, a large, prospective, randomized-controlled trial is needed to confirm these findings ((Chen KY, Kung WM, Kuo LT, Huang AP. Ultrarapid Endoscopic-Aided Hematoma Evacuation in Patients with Thalamic Hemorrhage. Behav Neurol. 2021 Jan 19;2021:8886004. doi: 10.1155/2021/8886004. PMID: 33542768; PMCID: PMC7843189.)). ===== Outcome ===== Thalamic hemorrhage bears the worst outcome among supratentorial [[intracerebral hemorrhage]] (ICH) ((Chen KY, Kung WM, Kuo LT, Huang AP. Ultrarapid Endoscopic-Aided Hematoma Evacuation in Patients with Thalamic Hemorrhage. Behav Neurol. 2021 Jan 19;2021:8886004. doi: 10.1155/2021/8886004. PMID: 33542768; PMCID: PMC7843189.)) ---- Concurrent IVH is strongly associated with mortality in patients with spontaneous thalamic hemorrhage (STH) . Delayed normal pressure hydrocephalus (NPH) may develop more frequently in STH patients with IVH who were treated with [[EVD]] ((Nam TM, Jang JH, Kim SH, Kim KH, Kim YZ. Comparative Analysis of the Patients with Spontaneous Thalamic Hemorrhage with Concurrent Intraventricular Hemorrhage and Those without Intraventricular Hemorrhage. J Korean Med Sci. 2021 Jan 4;36(1):e4. doi: 10.3346/jkms.2021.36.e4. PMID: 33398941; PMCID: PMC7781848.)). ---- Poor outcomes were associated with mass-related obstruction of the [[third ventricle]] from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from [[thalamic hemorrhage]] might become important in functional recovery ((Ullman NL, Tahsili-Fahadan P, Thompson CB, Ziai WC, Hanley DF. Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial. Neurocrit Care. 2019 Apr;30(2):380-386. doi: 10.1007/s12028-018-0610-0. PubMed PMID: 30251074; PubMed Central PMCID: PMC6420835. )). Basal ganglion (putaminal) or thalamic hemorrhage: surgery is no better than medical management, and both have little to offer ((Batjer HH, Reisch JS, Plaizier LJ, et al. Failure of Surgery to Improve Outcome in Hypertensive Putaminal Hemorrhage: A Prospective Randomized Trial. Arch Neurol. 1990; 47:1103– 1106)) ((Waga S, Miyazaki M, Okada M, et al. Hypertensive Putaminal Hemorrhage: Analysis of 182 Patients. Surg Neurol. 1986; 26:159–166)). ===== Case series ===== Retrospective analysis included 303 consecutive patients with spontaneous thalamic hemorrhage. Thalamic hemorrhage was classified into 4 types: anterior type (supplied mainly by the tuberothalamic artery), medial (mainly paramedian thalamic-subthalamic artery), lateral (mainly thalamogeniculate artery), and posterior (mainly posterior choroidal artery). The baseline characteristics, complications, and functional outcomes were assessed. The anterior type was found in 10 patients (3.3%), the medial type in 47 (15.5%), the lateral type in 230 (75.9%), and the posterior type in 16 (5.3%). Intracerebral hemorrhage volume was smallest in the anterior type, and significantly smaller than in the medial (P = 0.002) and lateral types (P < 0.001). Intraventricular hemorrhage (IVH) or acute hydrocephalus was significantly associated with the medial type (P < 0.01 or P < 0.01, respectively). Non-IVH or non-acute hydrocephalus was significantly associated with the anterior (P < 0.05 or P < 0.05, respectively) and lateral (P < 0.05 or P < 0.05, respectively) types. Emergency surgery was correlated only with the medial type (P < 0.01). The independent predictors of poor outcome were age (odds ratio [OR], 1.07; P = 0.002), admission National Institutes of Health Stroke Scale score (OR, 1.32; P < 0.001), and type of thalamic hemorrhage (OR, 2.08; P = 0.038). The present study proposed a novel anatomic classification of thalamic hemorrhage according to the major thalamic vascular territories ((Teramoto S, Yamamoto T, Nakao Y, Watanabe M. Novel Anatomic Classification of Spontaneous Thalamic Hemorrhage Classified by Vascular Territory of Thalamus. World Neurosurg. 2017 Aug;104:452-458. doi: 10.1016/j.wneu.2017.05.059. Epub 2017 May 19. PMID: 28532917.)) ===== References =====