A 68 yr old female who was a k/c/o Syst HTN presented with sudden onset fall in washroom in the morning and Altered Sensorium and was brought to ED...At presentation, her pupils were mid dilated and sluggishly reacting and b/l plantar response was Extensor....Discuss the treatment approach to this pt

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It's a case of midbrain bleed involving Lt thalamus,paraventricals & intraventricles c regional mass effect, midline shift to Rt c perifocal & cerebral oedema forming hydrocephalus.Pt has altered sensorium c sys HTN.Pt must be kept in CCU, ventilation support may require.Moist O2 inhalation, Foley's catheter,IV drip 12 hourly except 5D,Inj Mannitol 20% IV in jet 6 hourly,Inj Phenytoin IV tds, Glycerol 30 ml 6 hourly through Ryles tube(feeding also),Inj Citicholine 1 gm to charge in drip bd,Inj Furesemide IV SOS, Lactulose 6 tsf bd(see loose motion & SOS), Monitor PRT & BP every 30 minutes,Make input/output chart,asses GC & Glasgow coma scale.Go for ECG, Echocardiogram,CBC,RFT,LFT, Electrolytes, Bicarbonate,BSL,TSH,BTCT, Prothrombin time c INR.Treat accordingly.Repeat MRI brain & angiography,if condition improves see for obstructed hydrocephalus,if so plan must be taken for Ventricular wall Shunt.Neurosurgeon's opinion required.Would be Ventriculoperitoneal Shunt(typing mistake)

Thank you Dr Jason George
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She is a c/o brain hemorrhage and prognosis lookes to be poor. Since extensive cerebral oedema is there give her manitol drip to reduce cerebral oedema iv steroids and antibiotics keep vitals normal once pt regains conciousness and pupil start reacting neurosurgeon can plan for drainage of hematoma or decompression.but only vegetative life will be possible.

Injection furosemide is usually not given in raised icp Rather I would suggest inj 20 pc mannitol and if both not above 180/110 better to monitor bip closely Give ffpiv infusion Inj citicholine and edaravone have all been proved useless It's better to monitor bp look for signs like bradycardia and papillidema stertorous breathing or Cheyne stokes respiration and manage conservatively Put ryles tube and start feeding properly maintain input output Chest should be clear watch out for aspiration pneumonia Headend should be elevated prophylactic antibioticgi for foleys catheter inj eptoin or phenytoin iv 8 hourly If no persistently high give inj labetalol stat and maintain with iv infusionto keep the cerebral perfusion pressure above 60 mm of hg

C/0cva ich with intra ventricular extension Ist consent ...send all routine investigation Auscaltate pt for aspirated pneumonitis Anti edemal measure ( ing.mannitole 350 cc stat f/b 100 cc iv tds Anti epileptic Antihypertensive Bp should slowly decrease target 1st 180mmof hg to prevent hamperd posterior phembra circulation Ryless feeding Catherisation Ing ceftrioxone 2gm bd Ing pantaprozole 40 mg od Inj ondansetrone 4 mg TDs Syp lactulose Air bed to prevent bed sore Repeat abg 12 hrs Repeat rbs 12hrs Head end elevation to prevent aspiration

LT thalamic bleed with blood in the Midbrain with perforation of ventricular system including 4th ventricle. There is acute hydrocephalus with periventricular hypodensity.Small blood in the quadrigeminal cistern also. Prognosis seems to be poor. Involve the neurosurgeon urgently

Intracerebral bleed with midline shift, developing hydrocephalus., cerebral edema Anti edema/ anticonvulsants, / adequate nutrition ,hydration/ control comorbid conditions: good nursing care: Neurosurgeon’s opinion.

Left thalamic bleed with perforation to 3rd , lateral & bood in the 4th ventricle with hydrocephalus.suggest urgent neurosurgical consultation for hydrocephalus.clntrol of hypertension with active supportive care.

It is a case of SHT/ICH with intra ventricular extension with hydrocephalus Aggressive BP reduction Ventilatory support Anti edema measures Early neurosurgery opinion for intervention of hydrocephalus

Massiv brain haemorrhage with IV cerebral edema poor prognosis . Supportive and symptomatic treatment. I V Mannitol I V Steroids Antibiotics Citicholine BP control ICU Admission If stable Surgery

Firs t case,h/HT ,H/o fall , it's case of head injury.treatmen- to maintain tpr BP , IV manitol, antibiotics, NSAIDS sos.meanwhile invitation to be done and Neurology opinion should be taken.

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