The Periodical First Issue, May 2002

 

 
Editors Note SAGAS Objectives SAGAS News Stroke Epidemiology In Saudi Arabia
Hypertension In Saudi Arabia Do We Need A Stroke Group In Saudi Arabia? The Periodical Quiz The Periodical Case

The Periodical Case

History:

A 48-year-old man, who is a heavy smoker, hyperlipidemic and occasional drug user, presents with 3 hours history of sudden headache with vertigo. He also complains of speech difficulties, seeing double and left side weakness.  He has no other significant history.

Examination:

Conscious with intact higher mental functions (GCS of 15)

Right 3rd cranial nerve palsy

Left side hemiparesis

NIHSS of 10/42

CVS, chest and abdomen, normal

Hemogram, coagulation and biochemistry, normal

Working Diagnoses: 

Vascular event Right Midbrain Lesion (Weber’s syndrome) Caused by one of the following:

Brainstem hemorrhage, Brainstem infarction or Vertebrobasiar dissection

 

Investigations and hospital Course:

Initial CT Scan brain shows a midbrain hemorrhage with leak into the third ventricle with no hydrocephalus.

 

and a stat 4 vessel angiography shows no abnormalities

Admitted to ICU

4 hours later, severe deterioration (GCS around 7-8)

Stuperous
Neck stiffness
Elevation of MAP

Intubated and ventilated

Emergency external ventricular drain (EVD) with intracranial pressure (ICP) monitoring

Ct Scan 18 hours following EVD shows no collapse of ventricles and even further ballooning of third and lateral ventricles

The ICP monitor shows increased reading, with decreased CSF flow through the EVD indicating blockage due to blood clot.

Treatment:

2 mg rt-PA 12 hourly given through the EVD (total of 3 doses )

Continuous CSF drain with intermittent ICP measurement

 

All measures to maintain adequate CPP are taken

Follow up CT-scans

12 hours following rt-PA start, collapse of ventricles and improved CSF flow

 

3 days following rt-PA start, blood disappearing from third ventricle

 

EVD out after one week

Extubated

Good recovery (GCS 15 and NIHSS of 6/40)

Minimal neurological deficit

Case discussion

The use of intraventricular rt-PA is a well recognized treatment for intraventricular hemorrhage if there is a block to CSF flow through an EVD. This method should not be used unless there is no contraindication to the use of rt-PA.

Dr Waleed Khoja