A 39-year-old presents to the emergency department with severe headache and confusion starting 30 minutes ago. Physical exam on arrival is noteworthy for difficulty naming and right pronator drift, but rapidly deteriorated upon return from CT. They developed vomiting, global aphasia, and right hemiplegia before becoming unresponsive. Drug screen was positive for cocaine.
This patient is at risk of imminent herniation due to the development of hydrocephalus. They have midline shift from mass effect of the bleed. Intracranial pressure is acutely managed with IV hypertonic saline, mannitol, and hyperventilation as a bridge to definitive management. Neurosurgery can place an external ventricular drain, or EVD, and evaluate appropriateness for decompressive craniectomy.
The intracerebral hemorrhage (ICH) score is 2 (+1 for bleed volume and +1 for intraventricular extension), which is associated with a 26% mortality risk. Mental status is scored based on initial presentation, which was +0 in this case. The ICH score is a tool to assist with prognostication, but should not be applied fatalistically at the individual patient level, and is not intended to determine how aggressively to treat any individual patient.
- Figure 1 medical case
- Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
- Intracranial Hemorrhage Treatment & Management
1. Mcgurgan IJ, Ziai WC, Werring DJ, Salman RA-S, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Practical Neurology. 2020;21(2):128–36.
2. David S Liebeskind MD. [Internet]. Intracranial Hemorrhage Treatment & Management: Medical Care, Surgical Care, Consultations. Medscape; 2021 [cited 2021Nov3]. Available from: https://emedicine.medscape.com/article/1163977-treatment
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