Case Review With Massive ICH, IVH, Brain Edema and Acute HC

55 years old male Filipino patient known case of hypertension, was received in ER intubated on et tube 7.5, lip level 23 , complained of headache, right side body weakness , decrease level of consciousness.

Sedated with Midazolam 5ml \hr and fentanyl 10 mcg \hr infusion on going , foleys present 16  number , canula 20 gauge on left and right metacarpal , received in room trauma  attached with cardiac monitor.

Ordered CT brain , C xray , blood  investigation and ABG, meanwhile he was administered inj Labetalol 10mg (for HTN) ,inj Manitol 25mg, inj  Omeprazole 40mg, inj Metoclopramide 10mg.

Blood extraction done for cross matching and blood arranged in PRBC 2 unit in Blood bank.

CT technician came, patient shifted to CT scan.

MASSIVE ICH, IVH, BRAIN EDEMA. acute HC. PATIENT sedated, connected to ventilator, GCS 3-4/15, PUPILS ARE 4MM NON reactive, no brain stem reflexes BUT patient was on sedation, CT- brain repeated at ER IMMIDATLY. (patient passed more than 18 hours from hematoma diagnosis before coming to ER).

HEMATOMA WAS VERY BIG and increasing in size and involve brain stem and posterior fossa. with acute hydrocephalus and intraventricular bleeding and massive brain edema. But no tonsellar hernations. patient taken to the OR FROM CT, RT frontal EVD inserted. LT FRONTOTEMPORAL CRANTIOMY DONE, BRAIN WAS silent, no pulsation from brain when dura opened, hematoma removed, cavity washed, BP DURING was very low maintained by pressers only, pulsations seen on the brain after hematoma removed, but disappear after 1 min, patient coded. CPR started, operation already finished.

CT BRAIN WITHOUT CONTRAST

TECHNIQUE :

Non contrast MDCT scan for the Brain was performed in axial plane with coronal and sagittal reconstructions.
FINDINGS :
Large left intracerebral hematoma measures 8x6x8 cm in APxTxH respoectively with surrounding edema, there
is associated mass effect in the form of compression upon left lateral ventricle and dilated right lateral ventrice
and shifting midline strctures to the right side with left subfalacine herniation, uncal herniation and tonsillar
herniation
there is intraventricular hemorrhage in both lateral ventricles, third ventricle, fourthe ventricle and basal cisternsSubarachnoid hemorrhage in left temporal region.

CODE BLUE

• Initial rhythm was PEA. ACLS protocol was followed.
• The PT was coded multiple times and reached to ROSC few minutes apart. But he was unstable during ROSC.
• Necessary management was given. The PT had episodes Of SVT during ROSC and received synchronized shocks for them.
• The PT was on ventilator and chest was rising equally.
• The PT’s BP was fluctuating from very high to low (220/110 TO 90/60).
• The ECG showed ischemic changes and upon further examining the case, turned out that the PT is not a candidate for intervention as he is unstable and there is brain death clinically.
• ABG shows acidosis. He received fluids, HCO3 and CA GLUCONATE. (DURING ROSC)
• Started on dual inotrope support.
• WBC 21 and received antibiotic.
• HGT was normal.
• In the last cycle of code blue, he developed episodes of VF and VT and was given shocks. Later he developed asystole and code blue was terminated.

patient supine position, under aseptic condition.
RT frontal kosher point used to insert EXTERNAL VENTRICULAR DRAIN, CSF FULL OF IVH comes out. then tracted under skin and fixed.
closed. opening pressure more than 40 cmh2o. wound dressed
patient head turned to the rt side. with lt shoulder role. under aseptic condition. large frontal tempropartal decompressed craniotomy. done,
dura opened. brain was not pulsation, small craniotomy done. hematoma evacuated. and cavity washed carefully. surgicele put for hemostasis , no bleeding , drain put inside hematoma cavity. then dura covered the over drain without string. when the patent coded. CPR initiated . PT recovered for 6 times ,

Surgery report