Concluded Case

ANEURYSM BLEED WITH IVH

55yrs/F known Hypertensive presented to casualty today morning with Complaints of Sudden onset of Acute headache and vomittings followed by rapid neurological deterioration.H/o CVA 13yrs back O/e - Semiconscious,disoriented,Left hemiparesis present,There was reduced tone and power upper and lower limbs on the left,Pupils - B/l Normal size slow reactive,GCS - E2V2M4,BP - 200/100,PR -72,Spo2 -98 without oxygen support.,Temp -98°F DIAGNOSIS AND APPROACH??

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Concluded answer
Thanks to all for valuable opinion. NCCT HEAD shows ACOM aneurysm that has ruptured with intraparenchymal and intraventricular bleed.The patient expired 6hrs later due to cardiac arrest.
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A massive hypertensive intracranial hemorrhage in the ventricles, basal ganglia, thalamocapsular region, SAH , interhemispheric region . It is a hypertensive bleed precipitated by blood thinners like Aspirin and clopidogrel which patient must be taking for past history of CVA . Prognosis is guarded Mainly conservative treatment initially 1..Ventilation support after intubation to reduce intracranial pressure and improve cerebral hypoxia. 2.Gradual reduction of B.P with labetalol in drip to 130 / 80 mmHg as further reduction may further increase cerebral hypoxia 3.Immediately stop blood thinners. 4.Decongestive therapy with mannitol but rebound phenomena can occur .So use inj lasix initially. 5.AED"s , inj Pantoprazole, IV fluids, supportive treatment. 6.Once patient is stabilised a neurosurgical consultation for EVD to prevent hydrocephalus and reduce cerebral oedema
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There's presence of diffuse SAH with IVH with thick SAH along the interhemispheric region. Plz get a Ct angio sos DSA done. One of the first differential daignosis would be ruptured anterior circulation (acomm or daca) aneurysm. Patient shld be planned for further intervention depending on Ct angio/DSA findings in form of either aneurysmal clipping or endovascular intervention also triple H therapy should be considered so as to prevent vasospasm. If surgery either sub frontal approach or interhemispheric approach shld be attempted depending on the location of the aneurysm.
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Diffuse SAH,blood in the Rt tentorium,anterior inter hemispheric fissure,corpus callosum,3rd ventricle ,dependent blood in the posterior horn of both lateral ventricle with early dialatation of lateral ventricles. ACOMA ANEURYSM HAS TO EXCLUDE. SUGGEST CONTROL OF BP,NIMODIPINE,URGENT DSA/ CTA. NEUROSURGICAL REF & PT SHOULD BE IN THE NEUROSURGICAL ICU
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It's acom aneurysm.. get dsa
Valuable opinion
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Thanks to all for valuable opinion. NCCT HEAD shows ACOM aneurysm that has ruptured with intraparenchymal and intraventricular bleed.The patient expired 6hrs later due to cardiac arrest.

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