To present a rare case of symmetric hemorrhages in the bilateral basal ganglia with unique imaging findings and discuss potential pathophysiological mechanisms.

A 78-year-old woman with untreated hypertension experienced sudden onset of consciousness disturbance (Glasgow Coma Scale E1V1M2 score on admission) with a decerebrate posture. Head computed tomography (CT) revealed symmetric hemorrhages in the bilateral basal ganglia and acute hydrocephalus. Contrast-enhanced CT at the hyperacute stage showed bilateral contrast medium leakage in the early and delayed phases. The patient was transferred to a rehabilitation hospital with severe abulia after 60 days following bilateral ventricular drainage and blood pressure control. Several studies report bilateral basal ganglia hemorrhage, and some hypotheses regarding the underlying mechanisms have been suggested. However, its precise cause remains unclear.

This report is the first to demonstrate bilateral contrast medium leakage in the basal ganglia, which suggests simultaneous bilateral small vessel disruption.