• - A 52 year old man presents with sudden onset of right face, arm and leg weakness and inability to speak. 
    - PMH: Hepatitis C, severe uncontrolled HTN, GERD, DM type 2 
    - PSH: cholecystectomy 
    - +smoker 
    - Neurologic exam: 
          - GCS 4/5/3 
          - Left gaze deviation 
          - Right hemiplegia 
          - Receptive and expressive aphasia 
          - Right facial droop

    Figure 1. Noncontrast head CT scan demonstrates a large left frontotemporal and parietal intraparenchymal hemorrhage with surrounding edema and profound mass effect with left-to-right midline shift and subfalcine and uncal herniation

    1. What would you do to treat this patient?

    2. Regarding intracerebral hematomas (not specific to this case), what factor is associated with better outcome with surgical evacuation?

    3. What is the most likely underlying cause for the ICH presented here?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • first, I would like to have a angiography
    • Immediate endoscopic hematoma evacuation could be - also - a good treatment, if available.
    • Would evacuate but think patient is likely to do poorly.
    • Have lost interest in evacuating most hemispheric hematomas overall but since this one comes close to the surface would offer surgery to the family. Would counsel them about the grim prognosis, though.
    • This patient has radiographic evidence oh herniation at presentation. Unless there is a medical contra-indication to surgery he should have hematoma evacuated,even though it is in the dominant hemisphere.
    • would do MRI in 6-8 weeks later to R/o tumor versus cavernous malformation, post op would consider CTA to R/o AVM if not clear at time of surgery.
    • I Don't think a craniotomy can help htn therapy!
    • Did this exact same bleed last week except they called me as his pupil was blowing. Patient did great. Mild RHP and a little aphasia but remarkable recovery. BB over bleed site closest to skull on CT after pupil blew, small 3 cm crani, small 1cm dural cruciate opening just enough to get out clot for relaxation then larger dural opening and further clot evac with small 2 cm. cortical opening.
    • If I encounter excessive bleeding during opening I would perform hemicraniectomy without attempting cortical opening and hematoma evacuation
    • above answers based on no info on clinical deteriotion, MRI/CTA or MRA. With blood in sylvian fissure, options did not include identifying the source of bleeding. If anuerysm is exluded amyloid angiopathy would be the most probable cause.
    • Consider STAT CTA then hemicraniectomy, hematoma evac.
    • Surprised not having beside this CT an Angio CT to complete the preoperatory work up!!!
    • If his GCS deteriorates I would do a small craniotony and evacuate the hematoma. Is he on any anti clotting medication?
    • I would start with immediate bilateral ventriculostomies and than proceed with craniotomy and evacuation of the hematoma after correcting the possible coagulopaty and mannitol iv . act. I treated many patient with less deficit this way after trying other options with more disappointing results..
    • I would do a CT angio before any surgery, since there is subarachnoid hemorrhage. Although the hematoma location is unusual for an aneurysm, it is better to know this information before going in. His risk of deterioration appears to be relatively high with observation. Surgery rather than slogging it out with medical management will likely speed his recovery. The hemorrhage extends to the cortical surface, so additional damage to the dominant hemisphere is less likely.
    • I wonder if there is an associated SAH. If so I would have done a preop DSA to r.o. a vascular malformation
    • This might be also ischemia with hemorrhagic transformation which favors more or less conservative management. Another option not mentioned might be a delayed evacuation of the hematoma after stabilizing the blood pressure.
    • preop. CTA is needed
    • A craniotomy would allow effective evacuation of the hematoma and also give the facility to do duraplasty as significant edema is also present. Medical management will be given concurrent with surgical therapy. Craniotomy also allows for superior temporal gyrus and vein of labbe to be preserved
    • As the patient is unconscious, the superior functions , especially , speech can not be assessed. It may be preferred describing the abnormality of the verbal answer then stating receptive and or expressive aphasia. We have to include in the management, medical or surgical, the Intracranial pressure monitoring.
    • interesting case and mx
    • In question 5: none of the above
    • This is not a typical case of intracerebral hemorrhage. For every one case our group sees like this (young patient, hematoma near the surface) we see 10 or 15 cases of elderly patient with basal ganglia hemorrhage
    • I do miniflap craniotomy with evacuation of haematoma centre and controle of BP with other required treatments.
    • Aggressive management may not result in a good outcome. Patient has too many medical issues that could add to a poor prognosis.
    • Now retired
    • Age is an important consideration as well.
    • Angiogram - either CT / Angio or conventional should be done pre-operatively.
    • I practice in middle east
    • Following evaluation for Hypertension and controlling measures in place, one should go for surgery.
    • angioCT-scan before craniotomy
    • Surgical cases generally fare worse than medical management.
    • Surgical cases generally fare worse than medical management.
    • Patient requires control of hypertension, evalution of coagulation and angiogrphy. If normal will require evacuation of hematoma. Craniotmy is better approach. Because of Hep C maybe coagulopathy induced hematoma
    • L uncal herniation is well documented in his CTScan which makes the situation urgent.
    • discuss with family and present options and respect what might have been patients
    • Acuta CTA is needed!
    • It will be helpful to have an angio MRI or angiogram
    • I offer hemi-craniectomy with haematoma evacuation in hypertensive bleeds within 2 cm of cortical surface and midline shift IRRESPECTIVE of side of involvement.
    • BP control and ICP monitor would be first tx followed by hemicrani when stabilized if family wished to proceed
    • hematoma is cortical surface with significant mass effect.early craniatomy with evacuation.
    • hematoma isclose to cortical surface with significant mass effect.early craniatomy with evacuation.
    • nice one, quiet often
    • Needs craniotomy after vascular studies
    • We are not told about liver function tests (ie. INR) given history of hep C. This has a large influence on timing for surgery.
    • consider CT angio prior to surgery.
    • This is the case of a middle age woman with HCV, severe HTN and DM type 2. The most common cause of spontaneous intracerebral hemorrhage is HTN, but usually the bleeding is deep and more circumscribed. The CT shows subarachnoid hemorrhage and the aneurism (especially mycotic given the increased risk of associated infectious diseases in an patient with HCV and DM)is not to be excluded). Less than 1 cm from the cortex and more than 2 cm in diameter is an indication for surgery, especially taking into account the median line deviation and the uncal and subfalcine herniation. The fact that there is so much edema on the CT obliges us to think in cerebral venous sinus thrombosis whit venous stroke.
    • I do emergency miniflap craniotomy, evacuation of haematoma , control of BP and mx of other causes in NICU as emergency. Mass effect damage to other part of brain is the couse of poor outcome in ICH. Pt must be fit for operation under anaesthesia.
    • i think burhole ICH evacuation and ICU menagment is necessary to handel like this case. dr tulat mahmood neurosurgeon
    • Recently I published in Brazil JBNC- BRAZILIAN JOURNAL OF NEUROSURGERY) about a casuistic of 391 ICH where the pre operative neurologic status was the main factor for the survival rate.See Freitas, Mello et al- Spontaneous intracerebral hematomas:management and results of treatment in 391 patients, J.Bras. Neurosurg 23(2):108-117,2012
    • early evacuation of subcortical hematomas is clinically rewarding and I strongly recommend it...Dr Ishfaq
    • Ct angio should be performed, there is SAH!!!
    • I am a third year medical student.
    • Most probably a cerebral venous thrombosis (vein of labbe) and not the options enlisted here.
    • I actually practice in Panamá (central América)
    • Would appreciate expert commentary on case for maximal educational benefit
    • I would obtain a CT Angiogram prior to proceeding with surgery May need DSA
    • as gcs in this case is good and most likely diagnosis is hypertension bleed. however ct angio brain will be requested to exclude any underlying pathology.
    • In this case, There is mass effect of the hemorrhage principally, we must make a good decompression immediately Regards, Achmad Fahmi, MD Surabaya, Indonesia
    • The presence of SAH is worrysome for an underlying vascular lesion. His age is appropriate for either aneurysmal or AVM but the ICH blood pattern is not typical of an MCA rupture. I would certainly need further studies before venturing on treatment recommendations and I would suggest a CTA as a first choice but an MRI/MRA might also be appropriate. Of course catheter angiography would be the gold standard but carries more risk and requires mobilizing more resources without necessary being superior. With his GCS I would absolutely not consider immediate surgery without further diagnostic imaging.
    • Despite the dominant hemisphere location, I would consider early/rapid (not necessarily urgent) removal of the clot because it is likely to hypertensive, the patient is moderately young, there is already shift and he will deteriorate, and it is a lobar hematoma close to the surface. Because of it's size, if it is fully evacuated, he does not need a decompressive hemicraniectomy.
    • Craniotomy for clot evacuation will follow resusitation, blood pressure management and imaging including CT-angiogram and possibly catheter angiogram.
    • Want to know the answers at drmanku@gmail.com
    • very interesting
    • Dural Sinus thrombosis is an important cause for hematomas in this location.
    • treat these cases as earlier as possible for better outcome
    • The two Pubmed references are not of much help though.
    • I would treat medically in the ICU with frequent neuromonitoring, possibly insert an external ventricular drain. Would try to clarify resuscitation status of patient with substitute decision maker. If there was clinical worsening, decompressive craniectomy +/- hematoma evacuation may be an option depending on this.
    • Please add a review Of all the cases
    • the problem i may face while operating on these patients is uncontrolled hypertension as even if you do good hemostasis the chances of re bleed are high. and withe deconpressive craniotomy and dural grafting i can prevent the expected effects of brain edema
    • Amyloid angiopathy is probably the cause of the haemmorage. Some of my colleagues perhaps would wait and watch,control the hypertension and take a call later after a angiography. But i feel that the haematoma is large and the patient will benifit from evacuation.

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