Case Presentation on
Intracranial Cerebral
Hemorrhage
Presented by: Ali, Janisa O.
Personal History
65 years old male, M.I.K from
Bourdain, married and has 6
offspring, the youngest is 28 years
old, retired (was a driver), cigarette
smokers, right handed.
Chief Complaints
• Disturbed conscious level, with
right side weakness 5 day before
admission.
• The patient was brought
comatose to the ER.
History of Present Illness
• According to the statement of relative who brought the patient, they he was reasonably well
6 days before yhe night before admission, while eating dinner he felt weakness of the right
side of the body followed by sudden collapse.
• Since then, he is comatose in ICU.
• No history of fever, convulsion, trauma to the head.
• No symptoms suggest other system affection.
History of Past Illness
• He is Hypertensive, Diabetic on no treatment.
• No history of cardiac abnormality.
• Chronic kidney disease on conservative measures.
Family History
• Irrelevant
Examination
Patient is comatose, GCS
• Eye movement: Eye to pain - 2
• Speech : no speech - 1
• Motor response: no flexion to pain -3
Vital Signs
• BP : on admission 200/110
• Pulse : 110 regular, equal on both side of average
volume.
• Temp: 37.8°
• Respiratory Rate : 25/min
HEENT : Normal
Examination
Extremeties:
• Upper Limbs: no clubbing, no pigmentation, no pallor, normal
muscles and nerves.
• Lower Limbs: no edeme, no pigmentation
Back: no pigmentation, no swelling, no spine deformities
Examination
Neurologic Examination:
Level of responsiveness: Obstunded, arousable only with
repeated and painful stimuli: verbal output is intelligible or nil;
some purpose movements to noxious stimuli.
• Pupillary responses; RRR
• Eye movement
• Fundoscopic examination.
Corneal reflex; Intact
Examination
Motor examination;
• Muscle tone: hypotonia in 4 limbs equally distributed.
• Reflexes: hyperflexia in 4 limbs equally distributed.
Minengeal Sign: no minengeal irritation sign.
Respnse to Stimuli: Flexion attitude
Examination
Cardiac examination; Normal
Chest examination; there is a decrease air entry
bilaterally, harsh visicular breathing, coarse crackles,
expiratory rhonchi allover the chest.
Abdomen: Normal
Silent Features
Male,65 years,smoker,Diabetic,hypertensive and C
presented with sudden weakness of the right side of
the body and DCL.
He is now comatose
He is hypertensive and diabetic on no treatment.
There is no history of any cardiac abnormality.
He is a smoker for the last 40 years,used to take 30
cigarette/day.There is no family history of similar
illness.
Investigation
Investigation
Investigation
Investigation
Investigation
Investigation
Pelviabdominal US:
-Chronic parencymatous liver disease.
-Average sized spleen.
-Rt kidney:mild back pressure,no increased in
echogenicity or loss of CMD.
-Lt Kidney:sonofree.
-Otherwise normal sonographic study.
Management
Management
Epidemiology
Globally, about 17 million strokes occur every year
and stroke is the second leading cause of death after
coronary heart disease, and the third most common
causes of disability.
Epidemiology
Globally the incident of stroke due to ischemia is % , while
the incidence of hemorrhagic stroke (ICH & SAH) is 32%.
Men have a higher incidence of stroke tan women at
younger but not older ages, with the incidence is reversed
and higher for women by the age of 75 years and older.
Intracerebral hemorrhage on a hypertensive, diabetic patient and a cigarette smokers.
Presentation
Sudden onset
·Focal neurological deficit
·Progresses over minutes to hours
·Depends on location
·Symptoms include:
口 SUDDEN numbness or weakness of face,arm or leg
口 SUDDEN confusion,trouble speaking or understanding.
□SUDDEN trouble with vison.
SUDDEN trouble walking,dizziness,loss of balance or coordination.
SUDDEN severe headache.
Review of Anatomy
Emergency Diagnosis
and Assessment
1.A baseline severity score should be performed as part of the
evaluation of patients with ICH (Class l;Level of Evidence B).
2.Rapid neuroimaging with CT or MRI is recommended to distinguish
ischemic stroke from ICH (Class I;Level of Evidence A).
3.CTA and contrast-enhanced CT may be considered to help identify patients
at risk for hematoma expansion(Class llb;Level of Evidence B),and
CTA,CT venography,contrast-enhanced CT,contrastenhanced MRI,
magnetic resonance angiography and magnetic resonance venography,can
be useful to evaluate for underlying structural lesions including vascular
malformations and tumors when there is clinical or radiological suspicion
(Class lla;Level of Evidence B
ICH Score
Neuroimaging
口CT is very sensitive for identifying acute hemorrhage and is considered"goold standard";
口Gradient echo and T2"susceptibility-weighted MRI are as sensitive as CT for detection of acute
hemorthage and are more sensitive for identification of prior hemorrhage.
口CT angiography(CTA)and contrast-enhanced CT may identify patients at high risk of ICH
expansion based on the presence of contrast within the hematoma,often termed a spot sign.A
larger number of contrast spots sugggests even higher risk of expansion.
口MRI,magnetic resonance angiography,magnetic resonance venography,and CTA or CT
venography can identify specific causes of hemorhage,including arteriovenous malformations
tumors,moyamoya,and cerebral vein thrombosis.
DCT scans(without contrast enhancements):
sensitivity=89%specificity=100%
DMRI scan:
sensitivity=83%specificity=98%
CT imaging is also sensitive for detecting SAH (although by itself does not rule it
out),and CTA can readily identify intracranial aneurysms.
On CT brain,hemorrhage appears as
hyperdense region,i.e.more white
Treatment
Factors Recommendation
General Monitoring and
Nursing
Initial monitoring and management of ICH patient should place in an
intensive care unit or dedicated stroke unit with physician and nursing
neuroscience acute care expertise.
Airway and Breathing Supplemental oxygen should be provided to maintain oxygen saturation
>94%
Supplemental oxygen is not recommended in nonhypoxic patient with
acute ischemic stroke.
Mobilization Early mobilization of less severely affected patients and measures to
prevent subacute complications of stroke are recommended.
Nutrition A formal screening procedure for dysphagia should be performed in all
patients before the initiation of oral intake to reduce the risk of
pneumonia.
Insert a nasogastric tube, of the patient fails the swallow test
Consider PEG only if prolonged entered feeding is required.
Treatment
Infection and Fever Treatment for fever after ICH may be reasonable.
Sources of hyperthermia should be identified and treated. And
antipyretic medication should be administered to lower temperature in
hyperthermic patient with stroke.
Routine use of prophylactic antibiotics has not been shown to be
beneficial
Patient with suspected pneumonia or urinary tract infection should be
treated with appropriate medications.
Seizures Clinical as well as EEG documented seizures should be treated with
antiseizure drug
Prophylactic antiseizure medication is not recommended
Blood Glucose Glucose should be monitored. Both hyperglycemia and hypoglycemia
should be avoided
Treatment
Prolonged recumbency As regard ICH, after documentation of Cassation of bleeding
low-suncutaneous low-molecular-weight heparin or
unfractionated h may be considered for prevention of
venous thromboembolism in patient with lack of mobility
after 1-4 days from onset.
Patient with ICH should have intermittent access pneumatic
compression for prevention of venous thromboembolism
beginning the day of hospital admission.
Brain dehydration
measures
Corticosteroids should not be administered for treatment of
elevated ICP in ICH. in aggrement with international stroke
Foundation guidelines.

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Intracerebral hemorrhage on a hypertensive, diabetic patient and a cigarette smokers.

  • 1. Case Presentation on Intracranial Cerebral Hemorrhage Presented by: Ali, Janisa O.
  • 2. Personal History 65 years old male, M.I.K from Bourdain, married and has 6 offspring, the youngest is 28 years old, retired (was a driver), cigarette smokers, right handed.
  • 3. Chief Complaints • Disturbed conscious level, with right side weakness 5 day before admission. • The patient was brought comatose to the ER.
  • 4. History of Present Illness • According to the statement of relative who brought the patient, they he was reasonably well 6 days before yhe night before admission, while eating dinner he felt weakness of the right side of the body followed by sudden collapse. • Since then, he is comatose in ICU. • No history of fever, convulsion, trauma to the head. • No symptoms suggest other system affection.
  • 5. History of Past Illness • He is Hypertensive, Diabetic on no treatment. • No history of cardiac abnormality. • Chronic kidney disease on conservative measures.
  • 7. Examination Patient is comatose, GCS • Eye movement: Eye to pain - 2 • Speech : no speech - 1 • Motor response: no flexion to pain -3 Vital Signs • BP : on admission 200/110 • Pulse : 110 regular, equal on both side of average volume. • Temp: 37.8° • Respiratory Rate : 25/min HEENT : Normal
  • 8. Examination Extremeties: • Upper Limbs: no clubbing, no pigmentation, no pallor, normal muscles and nerves. • Lower Limbs: no edeme, no pigmentation Back: no pigmentation, no swelling, no spine deformities
  • 9. Examination Neurologic Examination: Level of responsiveness: Obstunded, arousable only with repeated and painful stimuli: verbal output is intelligible or nil; some purpose movements to noxious stimuli. • Pupillary responses; RRR • Eye movement • Fundoscopic examination. Corneal reflex; Intact
  • 10. Examination Motor examination; • Muscle tone: hypotonia in 4 limbs equally distributed. • Reflexes: hyperflexia in 4 limbs equally distributed. Minengeal Sign: no minengeal irritation sign. Respnse to Stimuli: Flexion attitude
  • 11. Examination Cardiac examination; Normal Chest examination; there is a decrease air entry bilaterally, harsh visicular breathing, coarse crackles, expiratory rhonchi allover the chest. Abdomen: Normal
  • 12. Silent Features Male,65 years,smoker,Diabetic,hypertensive and C presented with sudden weakness of the right side of the body and DCL. He is now comatose He is hypertensive and diabetic on no treatment. There is no history of any cardiac abnormality. He is a smoker for the last 40 years,used to take 30 cigarette/day.There is no family history of similar illness.
  • 18. Investigation Pelviabdominal US: -Chronic parencymatous liver disease. -Average sized spleen. -Rt kidney:mild back pressure,no increased in echogenicity or loss of CMD. -Lt Kidney:sonofree. -Otherwise normal sonographic study. Management
  • 20. Epidemiology Globally, about 17 million strokes occur every year and stroke is the second leading cause of death after coronary heart disease, and the third most common causes of disability.
  • 21. Epidemiology Globally the incident of stroke due to ischemia is % , while the incidence of hemorrhagic stroke (ICH & SAH) is 32%. Men have a higher incidence of stroke tan women at younger but not older ages, with the incidence is reversed and higher for women by the age of 75 years and older.
  • 23. Presentation Sudden onset ·Focal neurological deficit ·Progresses over minutes to hours ·Depends on location ·Symptoms include: 口 SUDDEN numbness or weakness of face,arm or leg 口 SUDDEN confusion,trouble speaking or understanding. □SUDDEN trouble with vison. SUDDEN trouble walking,dizziness,loss of balance or coordination. SUDDEN severe headache.
  • 25. Emergency Diagnosis and Assessment 1.A baseline severity score should be performed as part of the evaluation of patients with ICH (Class l;Level of Evidence B). 2.Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I;Level of Evidence A). 3.CTA and contrast-enhanced CT may be considered to help identify patients at risk for hematoma expansion(Class llb;Level of Evidence B),and CTA,CT venography,contrast-enhanced CT,contrastenhanced MRI, magnetic resonance angiography and magnetic resonance venography,can be useful to evaluate for underlying structural lesions including vascular malformations and tumors when there is clinical or radiological suspicion (Class lla;Level of Evidence B
  • 27. Neuroimaging 口CT is very sensitive for identifying acute hemorrhage and is considered"goold standard"; 口Gradient echo and T2"susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorthage and are more sensitive for identification of prior hemorrhage. 口CT angiography(CTA)and contrast-enhanced CT may identify patients at high risk of ICH expansion based on the presence of contrast within the hematoma,often termed a spot sign.A larger number of contrast spots sugggests even higher risk of expansion. 口MRI,magnetic resonance angiography,magnetic resonance venography,and CTA or CT venography can identify specific causes of hemorhage,including arteriovenous malformations tumors,moyamoya,and cerebral vein thrombosis. DCT scans(without contrast enhancements): sensitivity=89%specificity=100% DMRI scan: sensitivity=83%specificity=98% CT imaging is also sensitive for detecting SAH (although by itself does not rule it out),and CTA can readily identify intracranial aneurysms. On CT brain,hemorrhage appears as hyperdense region,i.e.more white
  • 28. Treatment Factors Recommendation General Monitoring and Nursing Initial monitoring and management of ICH patient should place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. Airway and Breathing Supplemental oxygen should be provided to maintain oxygen saturation >94% Supplemental oxygen is not recommended in nonhypoxic patient with acute ischemic stroke. Mobilization Early mobilization of less severely affected patients and measures to prevent subacute complications of stroke are recommended. Nutrition A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia. Insert a nasogastric tube, of the patient fails the swallow test Consider PEG only if prolonged entered feeding is required.
  • 29. Treatment Infection and Fever Treatment for fever after ICH may be reasonable. Sources of hyperthermia should be identified and treated. And antipyretic medication should be administered to lower temperature in hyperthermic patient with stroke. Routine use of prophylactic antibiotics has not been shown to be beneficial Patient with suspected pneumonia or urinary tract infection should be treated with appropriate medications. Seizures Clinical as well as EEG documented seizures should be treated with antiseizure drug Prophylactic antiseizure medication is not recommended Blood Glucose Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided
  • 30. Treatment Prolonged recumbency As regard ICH, after documentation of Cassation of bleeding low-suncutaneous low-molecular-weight heparin or unfractionated h may be considered for prevention of venous thromboembolism in patient with lack of mobility after 1-4 days from onset. Patient with ICH should have intermittent access pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission. Brain dehydration measures Corticosteroids should not be administered for treatment of elevated ICP in ICH. in aggrement with international stroke Foundation guidelines.