Concluded Case

CATASTROPHE IN HYPERTENSION

65yrs/F Diabetic and hypertensive presented with H/o Sudden onset drop in conscious level and vomiting yesterday. Chief Complaints Altered mental status, vomitting History HTN, Diabetes Vitals Bp -180/90,HR -110,RR -24,Spo2 -98% on room air Physical Examination GCS -11/15,Pupils - B// Small size reactive to light,Plantars B/l extensors Diagnosis DIAGNOSIS Management MANAGEMENT PLAN?

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Concluded answer

Left thalamic bleed with blood in the3rd and 4th ventricles,body of lateral ventricles and posterior horn of lateral ventricle with early hydrocephalus . Control BP. If the available CT done on yesterday ad rept CT today to look for hydrocephalus.If hydrocephalus is increasing ref to neurosurgeon.Otherwise also get opinion from Neurosurgeon. Active supportive management.

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A case of hypertensive left thalamic bleed mos likely a berry aneurysmal rupture with extension of haemorrhage in the lateral , 3td and 4th and 4th ventricle wi secondary hydrocephalus with mass effect Treatment is mainly conservative witj control of B.P , inj mannitol, AED'S but EVD may be required if hydrocephalus is increasing A c

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Left thalamic bleed with blood in the3rd and 4th ventricles,body of lateral ventricles and posterior horn of lateral ventricle with early hydrocephalus . Control BP. If the available CT done on yesterday ad rept CT today to look for hydrocephalus.If hydrocephalus is increasing ref to neurosurgeon.Otherwise also get opinion from Neurosurgeon. Active supportive management.

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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

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Criteria for surgery in such patient 1. Age less than 60( better in age less tahn 50). 2. Hematoma is surfacing (1 cm from cortex) As the age is more with deep seated thalamic bleed with IVH , should be managed conservatively as the outcome without surgery and with surgery remains same. If hydrocephalus is there, EVD can be done.

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Left thalamic hemorrhage with ivh, with evidence of mass effect, and hydrocephalus Pt may required EVD for lifesaving measure Get NSX opinion Cerebral decongestant, BP control and other supportive measures

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Acute CVA hemorrhage in lt ventricles leaking in rt inf ventricle midline shift Inj manitol Inj dexamethasone Inj Ceftriaxozone Inj lasix Monitor vitals Manage diabetes Control bp gradually

Lt. Thalamus bleed 4th ventricle affected as well, BP to be controlled and monitored regularly, elevate bed to 35-45 degrees. Ref. To Neuro surgeon for further management. Needs EVD.

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Neurosurgery reference was taken for surgery,but Patient attendant refuse to operate.

The clinical features of thalamic hemorrhage in terms of localization are of great interest in many studies. To better understand the relationship between the localization of thalamic hemorrhage and clinical features, we evaluated the characteristics of patients with four different topographic types of thalamic hemorrhage. patients with posterolateral thalamic hemorrhage had severe sensorimotor deficit. Neuropsychological disturbances in patients with posterolateral thalamic hemorrhage were prominent, with primarily transcortical aphasia in those with left-sided lesions and hemineglect and anosognosia in those with right-sided lesions. Several variants of vertical gaze dysfunction, skew ocular deviation, gaze preference toward the site of the lesion, and miotic pupils were frequent in posterolateral thalamic hemorrhage, particularly in the large type. Patients with small and large anterolateral thalamic hemorrhage were characterized by severe motor and sensory deficits; language and oculomotor disturbances were also observed, although less frequently than in posterolateral hemorrhage. Sensorimotor deficits were observed in patients with medial thalamic hemorrhage (moderate in small hemorrhages and severe in large hemorrhages because of involvement of the adjacent internal capsule). Language disturbances in patients with left-sided lesions and neglect in patients with right-sided lesions were seen only in large medial thalamic hemorrhage. Dorsal thalamic hemorrhage was rare and characterized by mild and transient sensorimotor disturbances. Among patients with dorsal thalamic hemorrhages, only those with large lesions had oculomotor and neuropsychological disturbances. Conclusions We concluded that despite clinical similarity among the four types of thalamic hemorrhage, there was some discrepancy in the clinical features of small and large thalamic hemorrhages. The most important predictors of death were initial consciousness, nuchal rigidity, maximum size, volume and ventricular extension of hemorrhage, and occurrence of hydrocephalus. Hypertension was the most frequent cause of thalamic hemorrhage in our patients (74%), and this result was similar to previous studies that indicated that hypertension was the major risk factor for intracerebral hemorrhage. we observed that at admission blood pressure was higher in the majority of cases. This observation was also reported by several authors and may be explained by an autonomic response to increased Treatment for Thalamic Stroke The goal of stroke treatment is to restore blood flow in the brain. Ischemic stroke (the type caused by a blood clot) is sometimes treated by clot-busting drugs like aspirin or tPA. Hemorrhagic stroke is usually treated through surgery to repair the ruptured blood vessel and reduce intracranial pressure. Stroke patients that receive swift, fast treatment usually experience less side effects and disability than those who receive slow treatment. This again is why stroke is a medical emergency. After treatment, rehabilitation will begin to restore the stroke side effects caused by the damage. Thalamic Stroke Recovery Process 1. Physical and Occupational Therapy 2. Sensory Reeducation Exercises 3. Functional Electrical Stimulation 4. Vision Therapy 5. Central Pain Management

intraventricular bleed..urgent neurosurgical ref, external vent drain ICU care.. most patients survive

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