Abstract Number ‐ 222: Spontaneous Simultaneous Bilateral Putaminal Hemorrhages in a Young Woman

Abstract

Introduction Spontaneous simultaneous bilateral basalganglia hemorrhage is an exceedingly rare condition with significant morbidity and mortality. Hypertension is the most common underlying etiology followed by intoxication and metabolic causes1. Methods Here we describe a 39‐year‐old woman with a spontaneous simultaneous bilateral putaminal hemorrhages believed to be secondary to amphetamine (Adderall) use and undiagnosed hypertension. Results A 39‐year‐old right‐handed woman with history of attention‐deficit/hyperactivity disorder (ADHD) on dextroamphetamine‐amphetamine (Adderall), white coat hypertension and prior gestational hypertension was brought to the emergency department due to sudden‐onset left hemiparesis, left foot numbness, gait instability, and an abnormal sensation in her right ear. On arrival, blood pressure was 239/139 mmHg. Patient was noted to be somewhat drowsybut was consistently regarding,able to respond, and had anosognosia, hypophonia, a right gaze preference, mild dysarthria, left arm and leg hypotonia, left hemiparesis and hypoesthesia involving face, arm and leg and brisk reflexes on the left side.Head CT revelated bilateral putaminal hemorrhages measuring 10mL on the right and 3mL on the left,with no intraventricular hemorrhage and minimal right‐to‐left midline shift.Patient was admitted to the neuro ICU and treated with a nicardipine infusion. CTA/MRI/MRV/MRA and catheter angiography revealed no underlying structural pathology. Furthermore, patient had a normal platelet count and coagulation profile. Urine drug screen was positive for amphetamines, and serum metanephrines (0.59 nmol/L) and normetanephrines (1.2nmol/L) were elevated in the setting ofAdderall use. Nicardipine infusion was discontinued on day one and she was started on carvedilol 12 mg bid and amlodipine 5mg daily. Adderall was discontinued and patient was counseled on avoiding stimulant medications use. At time of discharge her dysarthria had resolved but her left hemiplegia remained unchanged. She was discharged on day 5 of hospital stay to an inpatient rehabilitation facility. She was started on fluoxetine 20 mg daily for motor recovery at the rehabilitation facility. At her two months follow‐up visit, she was noted to have significant improvement in her left‐sided strength, hypoesthesia and left facial droop but had developed left arm and leg spasticity. She was started on a trial of dry needling with physical therapy prior to consideration of anti‐spasmodic medications or Botox injections. At her office visit, her blood pressure had been well controlled on lisinopril 10 mg and amlodipine 10 mg daily. Conclusions Overall, this case report highlights that amphetamine (Adderall) use is a potential cause of spontaneoussimultaneousbilateralbasalgangliahemorrhage.