Intracerebral Hemorrhage

Niko Steven G. Manlangit, MD

Zarieh Dawn Novela, MD
Starlet Rhonadez Oriel, MD
 Objectives
1. Present a case taken during Community Rotation
2. Develop the knowledge and skills necessary to
diagnose, manage and refer patient presenting
with patient’s chief complaint
3. Compare the important clinical findings helpful in
evaluating patients with differential diagnoses
4. Share current information, articles and/or
researches regarding the case
 General Data
• J.J.M
• 50 year old
• Male
• Married
• Filipino
• Catholic
• San Lorenzo Poblacion Taytay Palawam
• Admitted for the first time: October 12, 2016
Chief Complaint

• Headache
 History of Present Illness
• Known hypertensive with no maintenance medication.
• Patient had intermittent headache located on the temporal area,
Few month s throbbing in character, PS 7/10 temporarily relieved by Mefenamic acid
500m/tab. No consult was done.
PTA

• Patient was then apparently well while watching television patient

complained with severe, generalized headache PS 10/10, followed by
1 episode of non-projectile vomiting. According to his wife, patient was
2 hours PTA shouting and sobbing due to the severe headache.

• Patient lost consciousness with noted stiffening of the extremities

with upward rolling of the eyeballs and central cyanosis lasting for
about 3 minutes. Patient regained consciousness and was disoriented
Few minutes after but still complaining with the headache.
after
 History of Present Illness

• Patient was noted to be confused, disoriented and

was irritable.
• Another seizure was noted lasting for approximately
2-3 minutes described as shivering of the entire body
At the ER with central cyanosis. His initial BP was elevated at
195/121, Temp: 27.8, HR: 78, RR:21 SpO2: 97%.

• For further evaluation and management.

Admitted
 Past Medical History
• Elevated blood pressure but with no maintenance
medications.
• No significant past medical illnesses.
• No history of previous head trauma or any
operations.
• No known allergy to foods, drugs, dusts and etc.
 Family History
• Hypertension: maternal and paternal side
 Personal and Social History
• Status: Married with 2 children
• Education: Finished high school
• Occupation: Utility van driver
• Home: semi-concrete with 4 occupants well lit and ventilated
• Diet: varies, not picky with foods, >8 glasses of water
everyday
• Water Source: NAWASA, faucet, not boiled
• Toilet facility: water sealed
• Garbage disposal: not segregated, collected by dump track
everyday
• Pets: cats and chicken
• Vices:
– smoker for 7 years consuming 10 sticks/day
– Occasional alcoholic beverage drinker: 3x month (gin)
– Denies elicit drug use
 Review of Systems
• General: (-) fever (-) chills, (+) body weakness
• Skin: (-) itchiness (-) dryness
• HEENT: (-) (+) nausea,
(-) ear discharge, (-) nasal discharge
(-) pain in swallowing (-) neck stiffness
• Musculoskeletal:
(-) muscle pains
• Respiratory:
(-) dyspnea, (-) cough, (-) colds,
(-) DOB
• Cardiovascular: (-) cyanosis, (-) palpitations
• Gastrointestinal: (-) constipation, (-) diarrhea,
(+) vomiting
• Urinary: (-) urgency, (-) frequency,, (-) enuresis
• Nervous: (-) paralysis (-) oliguria
 Physical Examination
• General Survey:
– Awake, incoherent, disoriented, irritable, stretcher borne
– GCS 9 (E3V2M4)
• Vital Signs:
– Blood Pressure:
• 195/121 mmHg
– Cardiac Rate:
• 79 bpm
– Respiratory Rate:
• 21 rpm
– Temperature:
• 37.8°C
– O2 Sat:
• 97%
Physical Examination
SKIN:
– Brown skin, warm with equally distributed hair,
fair turgor, no active skin lesions
HEENT:
– Anicteric sclera, reddish palpebral conjunctiva,
pupils equal and reactive to light, no naso-aural
discharge, nasal septum midline, moist oral
mucosa, no tonsilopharyngeal congestion, no
cervical lymphadenopathies, supple neck, no
anterior neck mass
Physical Examination
HEART:
– adynamic precordium, normal rate, regular
rhythm, no murmur, PMI ath 5th Left Intercostal
space mid clavicular line

CHEST AND LUNGS:

– symmetrical chest expansion, no retractions,
clear breath sounds, no wheeze, no crackles,
tympanitic,
Physical Examination
ABDOMEN:
– flat, no abnormal pigmentation, normoactive
bowel sounds,
– No organomegaly
– Tympanitic

BACK:
– No tenderness
Physical Examination
Extremities:
– no gross deformities, full and equal pulse, no
cyanosis, no edema, intact reflexes on upper
and lower extremities
Physical Examination

Cranial Nerve
I Not assessed
II Pupils equally reactive to light, (+) ROR bilateral
III, IV, VI Extra-ocular muscles intact
V (+) corneal blink reflex
VII No facial asymmetry
VIII Not assessed
IX, X (+) Gag Reflex
XI Can move head side to side
XII Tongue is in Midline
Physical Examination
 Salient Features
 50 year old male
 Previous history of headache
 Elevated blood pressure with no maintenance
medication
 Smoker and alcoholic
 Severe headache
 Loss of consciousness
 Seizure
 Elevated blood pressure
Differential Diagnosis
Ruled in Ruled Out
Cerebrovascular  Hypertension with no
Accident maintenance
(Ischemic/hemorrhagic medication
stroke vs aneurysmal-  Severe headache
SAH)  Smoker and alcoholic
 Seizure
 Confusion/disoriented
Closed Head injury /  Persistent headache  No history of trauma
Traumatic Intracranial  Seizure
hematoma  Alcoholic
 Confusion/disoriented
Migraine  Headache (throbbing) ₓ Seizure, confusion
ₓ Asso symptoms: n/v,
photo/phonophobia,
aura
ₓ No family hx
CNSTumor (space  Headache
occupying lesion)  Seizure
Course in the WARD
Day of Admission

PR 76 Admit to ICU
RR: No NPO
spontaneous Monitor VSq1, NVSq1, I&O qshift
breathing IVF: PNSS 1L x12h
(intubated)
BP 190/111 Diagnostics: Plain Cranial CT scan, CBC, Na, K, RBS,
Temp 37.8 CT, BT, Protime, PTT

GCS 6 (E1V1TM4) Insert NGT and IFC

• Emergent head CT scan

 initial diagnostic test recommended in the diagnosis of
any new, sudden-onset, severe headache
• Lumbar puncture
 Recommended for patients with SAH after (-)CT scan
Ref: 2008 American College Of Emergency Physicians Clinical Policy On Acute Headache (Evidence-
Based Recommendations); Schwart’s Principle of surgery 10th edition
Course in the WARD
Day of Admission

PR 76 Admit to ICU
RR: No NPO
spontaneous Monitor VSq1, NVSq1, I&O qshift
breathing IVF: PNSS 1L x12h
(intubated)
BP 190/111 Diagnostics: Plain Cranial CT scan, CBC, Na, K, RBS,
Temp 37.8 CT, BT, Protime, PTT

GCS 6 (E1V1TM4) Insert NGT and IFC

• In patients with negative CT and LP, the diagnosis of

SAH can be excluded

Ref: 2008 American College Of Emergency Physicians Clinical Policy On Acute Headache (Evidence-
Based Recommendations); Schwart’s Principle of surgery 10th edition
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST

• Blood pressure
• balance the risk of stroke, rebleeding, and
maintenance of cerebral perfusion pressure
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST

• Oral nimodipine
• to reduce poor outcome from vasospasm
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST

• Prophylactic anticonvulsant therapy MAY be considered in

the immediate posthemorrhage period
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST

• Control raised intracranial pressure

 Causes free water diuresis, increased serum
osmolality and extraction of water from brain
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST
Course in the WARD
Day of Admission
Meds:
SD Nicardipine 10 mg in 90cc D5W x 20cc/h titrate to
keep BP <130/90
Nimodipine 30mg tabs (2 tabs q8h)
Diazepam 5mg now, then if with active seizure
Mannitol 20%, 2oo cc q4
Citicoline 1g IV q8
Paracetamol 300mg Iv q 4h RTC
Ranitidine 50mg iv q8
Tranexamic acid 1 amp
Cefuroxime 750mg q8h ( ) ANST
Lab results
CBC Na ↓ 124 mEq/L
WBC ↑ 21.5 K ↓ 3.23 mEq/L

Platelet 242 HGT ↑ 178 mg/dl

Bleeding time 2s
Hemoglobin 166
Cloting time 4.3 s
Hematocrit 43%
Neutrophils ↑ 82
Lymphocytes 13 Active Partial Thromboplastin Time
PT 28.9 s
Monocytes 4
Control 34.7 s
Eosinophils 1
Prothrombin Time
PT 10.6 s
Control 12.6 s
Activity 86.8 %
INR 1
Course in the WARD
Day of Admission
CT scan:
Intracerebral Hemorrhage Right with
Subarachnoid Hemorrhage/Epidural Hemorrhage
To consider Right Middle Cerebral Artery
Aneurysm – Bleed
Overall prognosis explained, condition warrants
surgery however locality does not have the facility
to operate

• Definitive aneurysm repair: Coiling vs Clipping

Course in the WARD
Day of Admission
CT scan:
Intracerebral Hemorrhage Right with
Subarachnoid Hemorrhage/Epidural Hemorrhage
To consider Right Middle Cerebral Artery
Aneurysm – Bleed
Overall prognosis explained, condition warrants
surgery however locality does not have the facility
to operate

• Outcome depends on several factors

 age, grade at time of presentation, comorbidities, and
perioperative complications during hospitalization
• Rebleeding complication
• most important cause of mortality and poor outcome
• ~80% of patients die or remain disabled
• >50% survivors have permanent neurologic disability,
Course in the WARD

Day 2
BP 74/43mmHg Start Norepinephrine single concentrate
HR 105
Temp 39.4

GCS 3 (E1V1TM1) Prognosis explained to the family

No spontaneous
breathing
Course in the WARD

Day 3
DNR Signed

8 PM DNR status noted

BP 0 Patient expired
HR 0 Postmortem care
Case discussion
References
• Schwartz’s Principles of Surgery 10th edition
• Sabiston Textbook of Surgery 19th edition