A 64-year-old male presented with sudden altered level of consciousness, left sided weakness and speech disturbances. He suffered from pulmonary carcinoma and was treated by radio and chemotherapy one year previously. The brain computed tomography scan without contrast injection (A) revealed multiple intracerebral hemorrhages with adjacent brain lesions and perifocal edema especially in the right fronto-parietal area and the left frontal lobe. Two of the fronto-parietal lesions were enhanced following contrast injection (B) (arrows). Brain magnetic resonance imaging confirmed the three hemorrhagic lesions especially on T2 gradient echo sequence (C). Laboratory data revealed no thrombocytopenia or blood coagulation disorders. The patient underwent urgent removal of both right fronto-parietal hematomas. During surgical evacuation, yellowish masses (arrows) were observed in the cortical surface of both lesions. The patient consciousness and neurologic symptoms somewhat improved after surgery. Unfortunately two weeks later, his clinical condition deteriorated and he died in the intensive care department. Pathological examination displayed the findings of metastatic brain tumors from pulmonary carcinoma. Multiple intracerebral hemorrhages (MIH) are unusual, mostly associated with brain amyloidosis, vasculitis, anticoagulant therapy, hematologic disorders, hemorrhagic infarction, or illegal drug abuse. Brain metastases can cause bleeding, however simultaneous multiple metastatic hemorrhages are rarely reported in the literature and could be easily confused with other more common etiologies of intracerebral hemorrhages. Metastatic-related MIH shows distinct characteristics in neuroimaging. It should be suspected if the intracerebral hemorrhage has surrounding edema, an enhanced solid mass within or near the bleeding and found in the subcortical area of the brain parenchyma.

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Corresponding author
Ali Akhaddar, Department of Neurosurgery, Avicenne Military Hospital of Marrakech, Marrakech, Morocco (akhaddar@hotmail.fr)