Intracerebral hemorrhage

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  • Intracerebral hemorrhage

    Presenter: Hsu Jin-Yi

  • Lt deep white matter hemorrhage extended to ventricle

    Oct. 7, 2014

  • Oct. 7, 2014

    Emergent Extraventricular drainage

    Lt 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

    Lt Sterostatic aspiration and Lt 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 diagnosisLt deep white matter intracerebral hemorrhage with Lt 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

  • Question1. Management of intracerebral hemorrhage

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

  • Crit Care Clin 30 (2014) 699717

    Cerebral amyloid angiopathy (CAA)

  • Crit Care Clin 30 (2014) 699717

    Cerebral amyloid angiopathy (CAA)

  • Crit Care Clin 30 (2014) 699717

  • Crit Care Clin 30 (2014) 699717

  • Crit Care Clin 30 (2014) 699717

    blood pressure

    reduction

    cerebral edema

    management

    surgical interven-

    tions

    coagulo-pathy

    reversal

  • Crit Care Clin 30 (2014) 699717

    surgical interven-

    tions

    ventriculo-stomy

    hematoma

    evacuation

  • J Intern Med 2004; 255: 257265.

    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;83:15231529

  • 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: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • Lancet 2013; 382: 397408

  • 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) 699717

  • Cerebral edema managementMannitol

    Steroid

    3% saline

    Hyperventilation

    cerebral edema

    managemen

  • Crit Care Clin 30 (2014) 699717

    blood pressure

    reduction

    cerebral edema

    management

    surgical interven-

    tions

    coagulo-pathy

    reversal

  • Crit Care Med 2013; 41:13251331

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

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

  • Crit Care Med 2013; 41:13251331

  • Crit Care Med 2013; 41:13251331

  • Crit Care Med 2013; 41:13251331

  • Crit Care Med 2013; 41:13251331

  • Crit Care Med 2013; 41:13251331

  • ConclusionHigh relationship with white matter lesion, deep structure and cerebellum

    No relationship with sex, age, HTN, DM.

    Crit Care Med 2013; 41:13251331

  • Neurology; 2010;74:15021510

  • Lancet 2013; 382: 397408

    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!