Intracerebral hemorrhage

Presenter: Hsu Jin-Yi

L’t deep white matter hemorrhage extended to ventricle

Oct. 7, 2014

Oct. 7, 2014

Emergent Extraventricular drainage

L’t deep white matter hemorrhage extended to ventricle

Oct.7, 2014

GCS: E2VTM5 SBP around 120-150

Oct.7, 2014

GCS: E2VTM5 SBP around 120-150

Oct.9, 2014

Drowsy consciousnessMal-function of the EVD, 3ml in recent 3 daysGCS: E2VTM4 SBP around 130-150=> Malfunction of the EVD, ==> Arranged brain CT to check position

Oct. 9, 2014

Correct position of the drain tube

Oct. 9, 2014

Correct position of the drain tube

Removal the EVD

Oct.7, 2014

GCS: E2VTM5 SBP around 120-150

Oct.9, 2014

Drowsy consciousnessMal-function of the EVD, 3ml in recent 3 daysGCS: E2VTM4 SBP around 130-150=> Malfunction of the EVD, ==> Arranged brain CT to check position

Oct.12, 2014

Removed endotracheal tube E3V3M6SBP: 140-160

Oct.14, 2014

Drowsy consciousnessGCS: E3V1M5 SBP around 120-150

Oct. 14, 2014 Oct. 9, 2014

New-onset of Right IVH

Oct. 14, 2014 Oct. 9, 2014

New-onset of Right IVH

L’t Sterostatic aspiration and L’t EVD

Oct.14, 2014

Drowsy consciousnessGCS: E3V1M5 SBP around 120-160

Oct.15, 2014

Post-OPGCS: E3VtM5 SBP around 130-170

Oct.14, 2014

Drowsy consciousnessGCS: E3V1M5 SBP around 120-160

Oct.16, 2014

GCS: E2VtM4 SBP: 120-160 Mal-function of the EVD

Oct.15, 2014

Post-OPGCS: E3VtM5 SBP around 130-170

Oct. 16, 2014

Correct position of the drain tube

Oct. 16, 2014

Correct position of the drain tube

Urokinase through the drain tube

Oct.20, 2014

Removed endotracheal tube E4V2M5SBP: 120-160

Oct.20, 2014

Removed endotracheal tube E4V2M5SBP: 120-160

Oct.30, 2014

Arranged Ventriculoperitoneal shunt

Final diagnosisL’t deep white matter intracerebral hemorrhage with L’t intraventricular hemorrhage s/p EVD, followed by right frontal ICH and right IVH s/p stereostatic aspiration and EVD s/p VP shunt

Intracerebral hemorrhage with intraventricular hemorrhage

Question

1. Management of intracerebral hemorrhage

2. The relationship between location of the intracerebral hemorrhage and intraventricular hemorrhage

Crit Care Clin 30 (2014) 699–717

Cerebral amyloid angiopathy (CAA)

Crit Care Clin 30 (2014) 699–717

Cerebral amyloid angiopathy (CAA)

Crit Care Clin 30 (2014) 699–717

Crit Care Clin 30 (2014) 699–717

Crit Care Clin 30 (2014) 699–717

blood pressure

reduction

cerebral edema

management

surgical interven-

tions

coagulo-pathy

reversal

Crit Care Clin 30 (2014) 699–717

surgical interven-

tions

ventriculo-stomy

hematoma

evacuation

J Intern Med 2004; 255: 257–265.

blood pressure

reduction

N Engl J Med 2013;368:2355-65

N Engl J Med 2013;368:2355-65

N Engl J Med 2013;368:2355-65

N Engl J Med 2013;368:2355-65

N Engl J Med 2013;368:2355-65

Neurology; 2014;83:1523–1529

Timing of SurgeryCerebellar hemorrhage

Brainstem compression

Hydrocephalus from ventricular obstruction

Intraventricular hemorrhage

For patients presenting with lobar clots >30 mL

For most patients with ICH, the usefulness of surgery is uncertain

Stroke. 2010;41:2108-2129

surgical interven-

tions

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Lancet 2013; 382: 397–408

Coagulopathy reversalINR greater than 1.4 caused by warfarin

1. Fresh- frozen plasma (FFP)

2. Vitamin K

3. Prothrombin complex concentrates

4. Recombinant activated factor 7 (rFVIIa)

coagulo-pathy

reversal

Crit Care Clin 30 (2014) 699–717

Cerebral edema managementMannitol

Steroid

3% saline

Hyperventilation

cerebral edema

managemen

Crit Care Clin 30 (2014) 699–717

blood pressure

reduction

cerebral edema

management

surgical interven-

tions

coagulo-pathy

reversal

Crit Care Med 2013; 41:1325–1331

Study deisionNationwide, prospective cohort (N= 1,604)

Method:Analyzed CT scan images taken within 48 hours after stroke onset

Crit Care Med 2013; 41:1325–1331

Crit Care Med 2013; 41:1325–1331

Crit Care Med 2013; 41:1325–1331

Crit Care Med 2013; 41:1325–1331

Crit Care Med 2013; 41:1325–1331

ConclusionHigh relationship with white matter lesion, deep structure and cerebellum

No relationship with sex, age, HTN, DM.

Crit Care Med 2013; 41:1325–1331

Neurology; 2010;74:1502–1510

Lancet 2013; 382: 397–408

1. Surgical hematoma treatment2. Reduction of hypertension3. Reversal of coagulopathies or anticoagulants4. Hemostatic therapy

Stroke. 2010;41:402-409

Back to our patientblood

pressure reduction

cerebral edema

management

surgical interven-

tions

coagulo-pathy

reversal

Back to our patientsurgical interven-

tions ventriculo

-stomy

hematoma

evacuation

Back to our patient

Relative high risk of IVH by the location

Surgical intervention is essential to our patient due to possibly obstructive hydrocephalus due to IVH

Intensive blood pressure control ( target SBP < 140) should be considered

Thanks for your attention!