Case of the day

ICH + IVH

A 58yrs old Hypertensive male presented to casualty with Sudden onset headache and vomitting followed by deep coma and irregular respiration.He was intubated and ventilated in casualty for airway protection given his decreased level of Consciousness.NEUROSURGEON HAS SEEN THE CASE explained poor prognosis and Advice surgery, Relatives not willing for surgery.Only palliative care. Chief Complaints Headache, vomitting History Bipolar disorder + HTN Vitals BP - 210/100,Temp - 100,HR -120,RR -32 Physical Examination Left hemiplegia,Pupils - B/l Semidilated fixed non reactive,GCS - E1M2V1 Investigations CT scan head(plan)

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Uncontrolled hypertension resulting in acute intracerebral hemorrhage in rt parietal region at hypothalamus and internal capsule Bleeding leakage in rt ventricle and midline shift to left Poor prognosis and outcome is vegetative life GCS is 4 making critical status Gradual control the bp Inj dexamethasone 8hrly Inj Ceftriaxozone Inj ondestron Inj pantaprazole Wait for response I

Thanx dr Praveen Yograj sir
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Rt thalamocapsuloganglionic bleed with extension to rt temporal lobe, hematoma is crossing the midline and pushing the 3r ventricle to left ,with tracking of blood to midbrain.There is perforation of blood to both posterior horn of both lateral ventricles 3rd and 4th ventricles.Thre is downward displacement with trans-tentorial herniation. Suggest supportive management. Major bleed with Extremly poor prognosis.

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Acute hypertensive- most likely aneurysmal rupture with right intraventricular and intracranial haemorrhage with low GCS, bilateral semidilated non - reactive pupils and a poor prognosis. Impending brain death - at the most intraventricular drain can be kept along with ventilatory support and decompressive therapy

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Rt gangliocapsular bleed with ivh with midline shift.. In view of very poor GCS 4, prognosis is poor But age 58, there is still hope If pt is not willing for hematoma evacuation and decompression which is most useful for this pt, an another option for EVD can be offered, which is minimal invasive and more helpful than any conservative measure Bp control and other supportive measure as per protocol

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Haemorrhage in sub archnoid With basal ganglia thalamic With ventricles 80 percent aneurysm rupture Rupture maybe due to hypertension cerebral oedema lobar region Already neurosurgeon is handling Perfusion test mri angio can be helpful

Acute hypertensive emergency with Rt intra ventricular and ICH. Neurosurgeon opinion

Thanks@Dr. Parveen Yograj sir
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ICH with midline shift B/L Semi dilated fixed Pupil non reactive GCS - E1M2V1 That's poor prognosis. Even after evacuation of hematoma swelling may appear after surgical procedure leading to mass effect. Post surgery will take too much time period in order to changes to be occurred or may lead to lethal complications. So surgery would be for life saving purpose & further way will be wait & watch. So if continue with conservative treatment then...Antihypertensive - Tab.Proto XL 100, Tab.Eritel ( if creat normal), etc can be use. To reduce swelling Mannitol & hypertonic saline can be given. IV .VIT K for 3 days can be given.

As Dr Manorama ranjan said it is right mid line bleed with involvement of thalamus, basal ganglion and internal capsule and further involvement of right temporal lobe. Inj mannitol 150cc.iv.tds Tab nimotop 30mg. 2 tabs TDS through Ng tube etc

Valuable opinion
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Right capsule ganglionic hemorrhage, seeping into midbrain, perilesional edema, ventricular effacement, and midline shift to right . Transtentorial herniation present . Poor prognosis. Anti edema measures

Thank you doctor
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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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