Intracranial haemorrhage

Case discussion

Marcus Seah & Daniel Ng

RSUP Dr. Sardjito UGM-NUS elective
Anesthesia emergency
Initial presentation
- Mr S, 67-yo Indonesian man presented on 16 May 1:00pm
- Loss of consciousness
- At outpatient clinic for appointment → Fell down
- Brought immediately to ER
- Past Medical History
- Ischemic heart disease
- Previous CABG (midline sternotomy)
- On warfarin
- Congestive cardiac failure (EF 30%)
- Diabetes mellitus
- Hypertension
- Smoker
Primary survey
Assessment Management

Airway Clear -
No noisy breathing / stridor

Breathing Tachypnoeic (21 bpm) Nasal prong → NRM

Use of accessory muscles BGA
Oxygen saturation 94% Chest XR

Circulation Tachycardia (118 bpm) ECG

Hypertensive (180/80 mmHg) Establish IV access
Capillary refill (<2sec) Urinary catheter
Input/output monitoring

Disability GCS 7 (E2V2M3) Urgent CT Head

Pupils 3/3 mm; equal and reactive to light Maintain airway
Capillary glucose (normal) Neurosurgical consult
NG tube + Nil by mouth

Environment & Coffee-ground vomitus Lenoprazole + NG aspiration

Exposure No other trauma
Secondary survey
Head GCS 7
No head injury
No maxillofacial trauma

Neck No trauma, deformities or neck injury

Chest Midline sternotomy scar

Heart: S1S2, no murmurs
Lungs: Bilateral breath sounds positive
No trauma

Abdomen Soft, non-tender; no guarding/rebound

Bowel sounds present
No trauma

Musculoskeletal No trauma, deformities, open fractures

Neurological Babinski +ve, hypertonia

Myoclonic jerking
History
- Fall
Pre Walking to clinic

During Loss of consciousness; no seizure

No head injury

Post Did not regain consciousness

Myoclonic jerks

- Left sided generalized weakness

- Gradual onset over 1-week; progressively worse
- No focal neurological signs (vision loss, facial drooping, receptive/expressive aphasia, balance)
- No vomiting, headache
- No previous seizure / epilepsy
- No previous stroke
- No fever, photophobia, neck stiffness
- No loss of weight/loss of appetite
History
- Past Medical History

Ischemic heart disease On warfarin

Congestive cardiac failure Ejection fraction 30%

Diabetes mellitus Poorly controlled

Hypertension Poorly controlled

- Smoker (cigarette in pocket)

Differential diagnosis
1. Haemorrhagic stroke
2. Ischemic stroke
3. Hypoglycemia/ hyperglycemia
4. First presentation seizure
Investigations
- Biochemical
- Full blood count
- Liver panel
- Renal panel + electrolytes
- Coagulation panel
- Blood glucose
- Blood gas analysis
- Imaging
- CT Head
- Chest X-ray
- ECG
Investigations
Imaging (Head CT)

1. Left frontal lobe ICH with perifocal oedema

- Narrowing of left lateral ventricle
- Subfalcine hernia (1.37cm)
- Uncal herniation to the left
- Increasing ventricle volume to 91cc
2. SAH in bilateral frontal lobes and temporal lobes,
with the involvement of left lateral sulcus
3. SDH of falx cerebri anterior
4. Oedema cerebri
Investigations
Imaging (Head CT)

1. Left frontal lobe ICH with perifocal oedema

- Narrowing of left lateral ventricle
- Subfalcine hernia (1.37cm)
- Uncal herniation to the left
- Increasing ventricle volume to 91cc
2. SAH in bilateral frontal lobes and temporal lobes,
with the involvement of left lateral sulcus
3. SDH of falx cerebri anterior
4. Oedema cerebri
Investigations
Biochemical test
FBC Liver Renal Blood gas Coagulation Blood
panel panel with analysis panel glucose
elctrolytes

Hb AST 44 U/L BUN pH 7.50 PTT 34.9 251 mg/dL

12.6g/dL (raised) 26mg/dL HCO3 29.1 seconds (raised)
(NCNC (raised) mmol/L (delayed)
anaemia) (metabolic
Creatinine alkalosis) APTT 42.9
1.65 mg/dL secondays
(raised) (delayed)

Potassium INR 2.88

2.3mmol/L (delayed)
(low)
Investigations
ECG No acute changes

Chest x-ray Cardiomegaly

Pulmonary oedema
Initial management
1. Reverse anticoagulation Fresh frozen plasma, co-factor
Vitamin K

2. Manage blood pressure Nicardipine

3. Manage raised ICP Elevate head of bed to 30°

Mannitol
Nexium drip
Fentanyl
Consider Endotracheal intubation

4. Seizure prevention Phenytoin

5. Manage co-morbidities Metabolic alkalosis → IV acid treatment

Hypokalemia → Potassium chloride
Stress ulcer → Lansoprazole
Hyperglycemia → Novomix

6. Supportive care Antibiotic prophylaxis → Ceftriaxone

Replacement fluids → 0.9% normal saline
Definitive management
- Neurosurgery referral for removal of bleed
Progress
1. Neurosurgical referral
○ Patient not for immediate surgery
○ INR too high → bleeding risk
○ Suggest: correct coagulopathy
2. Anesthesia
○ Rapid Sequence Intubation with controlled ventilation
i. Fentanyl 200mcg
ii. Rocuronium 50mg
○ Sedation
i. Propofol continuous infusion 25-100mg/kg/min
○ Analgesia
Thank you