Congratulations and Thanks Dr Prashant Vedwan for a complete and elaborate presentation of this case of Basal ganglia intracerebral haemorrhage. The most important aspect is that- this was one of the rare cases of basal ganglia haemorrhage- where early neurosurgical intervention with in 3 hours of admission saved an important life Although generally conservative treatment is indicated in basal ganglia haemorrhage Intracerebral hemorrhage is a neurologic emergency that requires immediate neuroimaging to differentiate it from acute ischemic stroke. " Intracerebral hemorrhage in the basal ganglia is usually caused by hypertension. " Patients presenting within the first few hours have a high risk of hemorrhage expansion and neurologic deterioration. " Prognosis is based on multiple factors, including volume and location of hemorrhage, age, level of consciousness, presence of intraventricular hemorrhage, and warfarin use. " Coagulopathy, if present, should be corrected. " Rapid blood pressure control is safe but does not improve the clinical outcome significantly. " Clinical trials have failed to prove benefit of the surgical treatment. " New endoscopic minimally invasive surgical techniques are being tested with encouraging results.
Thanks Dr Prashant . Systemic hypertension show a predilection for certain anatomic locations of hematoma: the basal ganglia ( the putamen in particular),the sub cortical white matter, and the thalamus account for 35% ,25% and 20% of ICHs respectively, where as the posterior fossa locations,the cerebellum and pons are responsible for 10% and 5% of cases. Irrespective of the anatomical locations the common pathogenesis in these hemorrhage involves the hypertension- induced degeneration of the media of small ( 50 to200micron) arteries called " hypo- hyalinosis " and / or the formation of" micro aneurysms " both of which occur preferentially in perforation or small subcortical arteries,thus resulting in the characteristic anatomical distribution of hypertensive ICH.
Hello dr Prashant Vedwan Thanx for tagging me Going through the case of ICH Yes very good and appreciative work done Yes i agree the cases of ICH OR INFARCT should always receive the neurological treatment in WINDOW period of 72 hrs In this case pt has E2V3M4 GCS score hence all good steps were taken Evacuation of ICH in basal ganglia a vital area of brain Pt was negligent of hypertension Congratulations for well managed efforts
MICE ILLUSTRATION INTRACEREBRAL HEMARGHE OR ANY INTRACRANIAL PROBLEMS BE SUBDURAL HEMATOMA STROKE HYPERTENSION R T ACCIDENTS HEAD INJURIES ALL HAVE TO BE TAKEN AS URGENT CASES IMMEDIATE INTERVENSION AND CONSULTATION OF NEURO SURGEON IN HEAD INJURIES IS VERY IMPORTANT IN CASES OF NON TRAUMATIC NEUROLOGICAL DISORDERS CONSULTATION OF NEUROLOGIST IS VERY IMPORTANT
Truly said...intracranial hemorrhage has devastating outcomes unless managed at right time. Thank u for sharing
Useful educative and congratulations to you and team. Comprehensive observations and information sharing with us. Thanks Dr.
Intracerebral hemorrhage in accident many causes in world.. that kind of situation neurological deterioration, patients head hemorrhage loss eye, manic disorders,coma,and etc.. surgical procedures is best for accident head heamorrhage.. treatment then seen the cases MRI then treatment start by neurologist
Nice thanks like to know the rebound effect of mannitol ⁰
Welldone sir with in. the time Thanks for immediate response t save the Life
Good case learning experience... this is what the best about this platform...
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Stroke (also known as Brain Attack) occurs when blood supply to the brain is affected due to either blockage or leakage (or both blockage and leakage) of a blood vessel responsible for supplying or draining blood to and from the brain, thereby, causing brain damage leading to difficulty in movements, sensation, speaking, vision etc. or at times to death. Types of stroke Ischemic Stroke:In India about 70-75% of all strokes are ischemic, in which blood flow to the brain is blocked by blood clots or fatty deposits (also known as plaque) in blood vessel linings. Hemorrhagic Stroke:It occurs when a blood vessel leaks in the brain. Blood accumulates and compresses the surrounding brain tissue. This is also called ‘Brain hemorrhage. Intracerebral hemorrhage: It is the most common type of hemorrhagic stroke. It occurs when an artery in the brain leaks, flooding the surrounding tissue with blood. Subarachnoid hemorrhage: It is bleeding in the area between the brain and its covering consisting of layers of tissue. Transient ischemic attack (TIA) is a "warning stroke" or a "mini-stroke" that results in no lasting damage. Recognizing and treating TIAs immediately can reduce your risk of a major stroke. Symptoms Stroke can affect any movement, senses, speech, behavior, thoughts, memory, and emotions. The body may become paralyzed or weak. The five most common symptoms of stroke are Weakness or Numbness of the face, arm, or leg. Confusion or trouble speaking or understanding others. Difficulty in vision Difficulty in walking or loss of balance or coordination. Severe headache with unknown cause. Causes Presence of following risk factors place people at increased risk for developing stroke. A.Non-modifiable Family history Old age Male sex B.Modifiable High blood pressure Diabetes High cholesterol Heart disease Smoking (as it injures the blood vessels and speeds up the hardening of the arteries) Consuming excessive alcohol (as it increases the blood pressure) Low socioeconomic status Source : NHPDr. Hemant Adhikari25 Likes35 Answers
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59 years old Diabetes patient operated earlier for ASD presented with stroke left he Mille his with motor aphasia. I agreed with my most of friends who mentioned Atrial Fibrillation leading to CVA right MCA Infarction as First Admission CT scan and ECG revealed. Some of the patients develop AF after surgery for ASD. She has permanent AF for the past 4-5 years and on oral Anticoagulation earlier acitrom and on NOAC Rivarobaxan 20 mg daily for the one year. However for the past 3 months on irregular Oral Anticoagulation due to her travel to USA and back. She was back from her trip abroad just week back and presented to Tathagat with Sudden onset stroke within 2 Hours after Stroke. According to latest stroke management AHA guidelines and consultation with neurologist Thrombolytics can be given within 4.5 hours but still with risk of hemorrhagic transformation . Patient was given Tenectaplase 30 mg IV bolus. However patient did not improve and her sensorium worsened early morning and repeat CT revealed Hemorrhagic transformation with midline shift. Emergency craniotomy performed to relieve raised ICT. However her GCS score worsened and pupils dilated and fixed. She was declared brain declared brain dead. We could convince educated family and agreed for organ donation and body donation to medical college. Thrombolysis Guidelines The American Heart Association/American Stroke Association (AHA/ASA) inclusion guidelines for the administration of rt-PA in under 3 hours are as follows : Diagnosis of ischemic stroke causing measurable neurologic deficit Neurologic signs not clearing spontaneously Neurologic signs not minor and isolated Symptoms not suggestive of subarachnoid hemorrhage Onset of symptoms less than 3 hours hours before beginning treatment No head trauma or prior stroke in past 3 months No MI in prior 3 months No GI/GU hemorrhage in previous 21 days No arterial puncture in noncompressible site during prior 7 days No major surgery in prior 14 days No history of prior intracranial bleed Systolic blood pressure under 185 mm Hg, diastolic blood pressure under 110 mm Hg No evidence of acute trauma or bleeding Not taking an oral anticoagulant, or if so, INR under 1.7 If taking heparin within 48 hours, a normal activated prothrombin time (aPT) Platelet count of more than 100,000/μL Blood glucose greater than 50 mg/dL (2.7 mmol) No seizure with residual postictal impairments Computed tomography (CT) scan does not show evidence of multilobar infarction (hypodensity over one-third hemisphere) The patient and family understand the potential risks and benefits of therapy In May 2009, and again in March 2013, the AHA/ASA guidelines for the administration of rt-PA following acute stroke were revised to expand the window of treatment from 3 hours to 4.5 hours to provide more patients with an opportunity to receive benefit from this effective therapy. Eligible patients should receive rtPA therapy as soon as possible, ideally within 60 minutes of hospital arrival. IV fibrinolysis can be considered in patients with rapidly improving symptoms, mild stroke deficits, major surgery within the past 3 months, and recent myocardial infarction; risks should be weighed against benefits. Eligibility criteria for treatment in the 3 to 4.5 hours after acute stroke are similar to those for treatment at earlier time periods, with any 1 of the following additional exclusion criteria: Patients older than 80 years All patients taking oral anticoagulants are excluded regardless of the international normalized ratio (INR) Patients with baseline National Institutes of Health Stroke Scale (NIHSS) score > 25 Patients with a history of stroke and diabetes Patients with imaging evidence of ischemic damage to more than one third of the middle cerebral artery (MCA) territory A Scientific Statement from the AHA/ASA, “Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke,” published in 2015, contained recommendations further elucidating the eligibility criteria for rtPA (alteplase) therapy in patients with acute ischemic stroke. Those recommendations included, but were not limited to, the followin: For otherwise medically eligible patients aged 18 years or older, intravenous alteplase administration within 3 hours is equally recommended for patients under age 80 years and older than age 80 years For severe stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of ischemic stroke For patients with mild but disabling stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of ischemic stroke Intravenous alteplase treatment in the 3- to 4.5-hour time window is recommended for those patients under age 80 years who have no history of both diabetes mellitus and prior stroke, who have a NIHSS score under 25, who are not taking any oral anticoagulants, and who have no imaging evidence of ischemic injury involving more than one third of the middle cerebral artery territory Intravenous alteplase treatment is reasonable for patients who present with moderate to severe ischemic stroke and demonstrate early improvement but remain moderately impaired and potentially disabled in the judgment of the examiner The time from last seen normal to treatment with intravenous alteplase should be under 3 hours for eligible patients with the use of standard eligibility criteria Intravenous alteplase administration is recommended in the setting of early ischemic changes (EICs), seen on CT scan, of mild to moderate extent (other than frank hypodensity) For EICs on CT scan, administering intravenous alteplase to patients whose CT brain imaging exhibits extensive regions of clear hypoattenuation is not recommended Intravenous alteplase is reasonable for the treatment of acute ischemic stroke complications of cardiac or cerebral angiographic procedures, depending on the usual eligibility criteria Intravenous alteplase is recommended for patients taking antiplatelet drug monotherapy before stroke on the basis of evidence that the benefit of alteplase outweighs a possible small increased risk of symptomatic intracerebral hemorrhage (sICH) Benefits and Risks of Thrombolytics The chief benefit of thrombolysis is improved final functional outcome through reperfusion salvage of threatened tissue. The chief risk is intracerebral hemorrhage. With intravenous thrombolysis, about 6% of patients have intracerebral hemorrhage associated with early worsening,and half of these patients have their final outcome altered as a result. With intra-arterial thrombolysis, about 10% of patients have major early hemorrhage, but again many of these occur in already infarcted fields and do not clearly alter final outcome. Other less frequent complications of thrombolytics include systemic hemorrhage, angioedema, and allergic reactions. Follow-up Further Inpatient Care After thrombolytic therapy is initiated, transfer the patient to an intensive care unit, stroke unit, or other unit capable of close observation. No antiplatelet or anticoagulant therapy should be administered for 24 hours following tPA. Obtain a repeat head CT scan or MRI 24 hours after tPA to rule out asymptomatic hemorrhagic transformation prior to initiating antithrombotic therapy. Blood pressure should be monitored closely and controlled. Physical, occupational, and speech therapy can be initiated after the first 24 hours of bedrest. Obtain neurosurgery and hematology consultation. Transfer Transfer should be initiated if CT or MRI is not available. However, remember that the time to transfer a patient may exceed the 3-hour time-window for treatment. Complications Intracerebral hemorrhage In the NINDS trials, the rate of combined minor and major symptomatic ICH (ie, any clinical worsening temporally coincident with any new ICH) 24-36 hours after treatment was 6.4% with tPA versus 0.6% without tPA. ICH may be signaled by acute hypertension, headache, neurological deterioration, and nausea or vomiting. If ICH is suspected, obtain an emergent head CT scan and obtain PT, aPTT, platelet count, and fibrinogen. If ICH is present on CT scan, evaluate lab studies and administer, if needed, 6-8 units of cryoprecipitate containing fibrinogen and factor VIII, 6-8 units of platelets, and/or fresh frozen plasma. Use of recombinant factor VII may also be considered but carries a risk of inducing thrombotic events. Other complications may include oozing from intravenous line and venous puncture sites (up to 30% of cases) and angioedema, although this is rare. Prognosis Three months following tPA therapy, approximately 30% of patients are neurologically normal or near normal; 30% have mild to moderate neurological deficits; 20% have moderate to severe neurological deficits; and 20% have died. Three months following tPA therapy, approximately 50% of patients are completely or almost completely independent in activities of daily living; 15% are moderately dependent on others; 15% are completely dependent on others; and 20% have died. 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Cva Left hemiparesis. 35 yr old female. not hypertensive not diabetic. is it young stroke? Right Middle cerebral artery infarct?Balaji Prabu1 Like16 Answers
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