MORTALITY CASE PRESENTATION:

ACUTE HYPERTENSIVE INTRACEREBRAL AND INTRAVENTRICULAR

BLEEDING IN A PATIENT WITH COMORBIDITIES

DEPARTMENT
OF
NEUROSURGERY
PRESENTED BY:
DR. GANDHI BHASKAR PATRUDU LANKA MBBS, MD, MA, MS, (MCh)
RESIDENT NEUROSURGERY (YR-2)

DR. V.R. SARDANA (PROFESSOR & HEAD);

DR. SANJEEV ATTRY (PROFESSOR);
DR.V K GUPTA (PROFESSOR); DR. A VERMA (ASSISTANT PROFESSOR);
DR. JAYANT JAIN (ASSISTANT PROFESSOR);
PROF. (DR.) SAURABH BHARGAVA ( CHIEF INTENSIVIST & NEUROANAESTHETICS )
PRESENTATION AND HISTORY

 An 82-year gentleman, a resident of Jaipur

was brought to NIMS on 30/04/2023 at 10
pm. with an A/H/O sudden fall on the ground
while walking at home at around 4.30 pm and
with loss of consciousness since then. He had
no h/o of vomiting/ seizures/ENT bleeding.
He was a known case of HTN and DM on
irregular medication. He was a chronic
smoker and alcoholic for many years.
EXAMINATION

 GCS on arrival was E1V1M2, Pupils were

Right 4mm non-reactive. Left 2 mm non-
reactive, Vitals were: PR 92/min, BP 240/104
mmHg, Spo2 98% on RA, Temperature:98.6F.
 The patient was intubated in emergency in
view of low GCS
Chest X ray on admission
NCCT SCAN
LARGE INTRAPARENCHYMAL
HEMORRHAGE
IN RIGHT CEREBRAL HEMISPHERE

EXTENSION IN BILATERAL LATERAL

VENTRICLE

MIDLINE SHIFT OF APPROX 15MM

TOWARDS LEFT SIDE.
ECG

ECG s/o:
Premature ventricular contraction
Left atrial enlargement
T wave abnormality in V3, V4, V5
Prolonged QT interval
MANAGEMENT
 On the day of arrival, the patients attendants were advised of the need for
emergency surgery but even after repeated counseling, they denied any
surgical intervention.

 On next day, they agreed to surgical intervention and the patient was taken
up for emergency surgery.

 Procedure: Right side middle frontal gyrus cortisectomy with the evacuation
of hematoma and left side External Ventricular Drain placement in left
frontal horn through Kocher’s point was done on 1/5/2023.
 The patient was shifted to Neurosurgery ICU under sedation and paralysis.
 Post OP, the Patient was electively ventilated, paralyzed, and sedated.
 Postoperatively the pupils are of equal size(anisocoria resolved) but b/l pupils

were still non-reactive.
POST OP CT SCAN
 Post-op ct scan shows that the brain has got
relaxed, there was evacuation of right side
intracerebral hematoma and no mass effect or
midline shift is seen now; and the tip of External
Ventricular Drain is seen in the left frontal horn.
 POD2 to POD 4, GCS remained same (E1V1M2).
I/V/O poor GCS the patient was tracheostomised .
 Patient continued to have poor GCS and was
monitored in Neuro ICU on ventilator support.
 Blood investigations showed deranged RFT
(Creatinine 1.73 and urea 51). RFT trend
continued to deteriorate, for which a
Nephrology reference was taken. They
advised us to avoid Nephrotoxic drugs and to
start Injections of Lacarnit and Optineuron
and to monitor the urine input and output.
ECG ON POD 5 (6/5/2023) 8.49 AM

ECG s/o :
Atrial Fibrillation
Biphasic T wave V4
Slight ST depression (V2)
Middle ST elevation (V6)
2D ECHO on 5/5/2023
 Concentric LVH with Normal systolic function

 No RWMA, LVEF 50%

 Trace MR / No AR

 Moderate TR

 IVC-1.7 cm >50 %.

 No Clot /Pericardial effusion

 A cardiology reference was taken because of
atrial fibrillation for which they have advised
amiodarone infusion, which was started.
 The patient continued to have raised BP for
which they have advised to continue Telmisartan
and Labetalol infusion
 From POD 7 b/l air entry decreased, and crepts
were present in bilateral lung fields. By POD 9
fio2 had to be increased to 100 % to maintain
saturation.
 On 9/05/2023(POD 8) late at night, the patient started
developing hypotension for which ionotropic support was
initiated.

 On 10/5/2023 at 7.15 am pt had an acute cardiorespiratory

arrest for which CPR was done and the patient was revived
back to life.

 At 8.05 AM the patient again had cardiac arrest for which once
more CPR was done but the patient could not be revived and
was declared dead on 10/05/2023 at8.57 am
Chest X ray POD 5 (6/5/2023)
CAUSE OF DEATH

 The cause of death is presumed to be acute

hypertensive Intracerebral and
intraventricular bleeding with comorbidities
of known chronic hypertension, diabetes and
chronic kidney disease.

 INVESTIGATION CHARTS
Investigation 1/05/20223 6/05/2023 8/05/2023 9/05/2023

HB 13.6 11.0
TLC 12.38 3.14
PLT 129 111 103
Urea 51 68
S. creat 1.73 2.15 1.90

PT 16.1 13.5
INR 1.19 1.00
Na 137 138 143.5 136.3
K 3.6 3.3 3.65 4.0
Cl 111 109 110.3 98.1
 VITAL CHARTS
Investigation 1/05/2023 6/05/2023 8/05/2023

PR Min:77 Min:63 Min:61

Max:101 Max:79 Max:96

RR Min:12 Min:11 Min:12

Max:21 Max:12 Max:12

Temp Min:98.1 Min:96 Min:98.2

Max:99.2 Max:99 Max:99.4

BP Min:90/59 Min:93/63 Min:86/59

Max:162/80 Max:160/90 Max:150/77

SPO2 Min:95 Min:96 Min:90

Max:100 Max:100 Max:99

GCS Min:E1VTM2 Min:E1VTM2 Min:E1VTM2

Max:E1VTM2 Max:E1VTM2 Max:E1VTM2

I/O 1820 3180 3200

O/P 1150 1600 1602
Thank you