A 62-year-old businessman of Japanese descent is brought to the emergencydepartment less than half an hour after he experienced a generalized tonic-clonicseizure during a dinner meeting. His consciousness is markedly diminished(he is incoherent and barely arousable).
A 62-year-old businessman of Japanese descent is brought to the emergencydepartment less than half an hour after he experienced a generalized tonic-clonicseizure during a dinner meeting. His consciousness is markedly diminished(he is incoherent and barely arousable).HISTORYAccording to his wife, the patient had been in fairly good health except forhypertension of 20 years' duration, for which he takes an angiotensin-convertingenzyme (ACE) inhibitor and a diuretic. However, during times of peakbusiness activity and stress, his adherence to antihypertensive therapy is suboptimal.Five years earlier, he was hospitalized briefly for a hypertensive urgency/emergency.PHYSICAL EXAMINATIONThe patient is afebrile. Heart rate is 60 beats per minute; respiration rate,12 breaths per minute; and blood pressure, 180/120 mm Hg. Pupils are roundand equal in diameter, and they react normally to light. Doll eye reflex appearsintact. No carotid bruits are audible, and heart and lungs are normal. The uvulaappears to be midline, but the gag reflex seems suboptimal. Spontaneous movementsof the right side are present, but the left arm and leg appear flaccid. Nopathologic reflexes are noted.LABORATORY AND IMAGING RESULTSHemogram is normal, as are serum electrolyte levels. Creatinine level is1.4 mg/dL, and blood urea nitrogen level is 25 mg/dL. An ECG shows earlyevidence of left ventricular hypertrophy by voltage criteria but no acute injurycurrents. An emergency CT scan without contrast reveals an 18-mL intracerebralhematoma in the region of the right basal ganglia. No interventricularhemorrhage is noted.Which of the following maneuvers would be of least benefit to thispatient?A. Initiation of anticonvulsant therapy for at least 30 days.
B. Elective intubation and mechanical ventilation.
C. Administration of intravenous antihypertensives to lower his blood pressurein the short term by about 25%.
D. Prompt cerebral angiography to determine whether secondary causesof intracerebral hemorrhage are present.
CORRECT ANSWER: DThis case is highly typical of spontaneous intracerebralhemorrhage. Intracerebral hemorrhage accounts for 10% to15% of strokes in the United States. However, hemorrhagicstroke is far more serious than thromboembolic stroke: it isresponsible for 38% of all stroke-related mortality.1From an epidemiologic perspective, this patient is aclassic hemorrhagic stroke victim. This type of stroke is:
Hypertension is by far the most important risk factor;the risk is strongly related to the degree of hypertension,and risk reduction is related to its pharmacologiccontrol.The sudden onset of this man's altered level of consciousnessand his sensorimotor deficit, which suggests internalcapsule involvement, are consistent with a commonsite of hemorrhage--the basal ganglia area--and a commonsource--the branches of the middle cerebral arterythat penetrate the lenticular nucleus of the corpus striatum.The initial CT scan--appropriately without contrast--confirms the presence of bleeding, provides an estimatedhematoma size of 18 mL (based on current CT techniques),and shows no bleeding yet into the ventricles.
Management issues in hemorrhagic stroke.
Becausehe experienced a seizure at the onset of hemorrhage,this patient is a candidate for anticonvulsants. Mostseizures occur within 24 hours of the acute event. There islittle chance that such early seizures will recur, and anticonvulsantscan be stopped after 30 days (choice A). However,later seizures (those that occur more than 14 daysafter the acute event) are associated with a higher risk ofrecurrence and chronicity and thus require indefinitemedical therapy.Blood pressure elevation frequently occurs both beforeand after intracerebral bleeding, and there is controversyabout how hypertension should be managed in patientswith stroke. However, because this man has a history ofchronic hypertension--which likely is poorly controlled--he is a candidate for cautious lowering of his blood pressure(choice C) according to the American Heart Associationguidelines.
Airway protection (choice B) is a less controversialarea of management. Our patient fulfills multiple criteriafor emergency intubation and ventilation. His level of consciousnessis significantly decreased, and the reflexes thatprotect the airway are impaired. These problems can leadto secondary injury from hypoxia and aspiration, whichwould worsen prognosis and eventual outcome.Proceeding to immediate cerebral angiography toidentify secondary causes of the bleeding (eg, arteriovenousmalformation, intracranial aneurysm, or neoplasm)(
) is incorrect on several grounds. According tostatistics, the basal ganglia location of this patient's hemorrhage,his preexisting hypertension, and his age makea secondary cause extremely unlikely.
Nor is there a"presurgery" indication for angiography.
The size (lessthan 30 mL) and location (deep in the brain) of his intracerebralhematoma make him a poor candidate at thistime for traditional transcranial surgical evacuation; thedamage produced by transcranial surgery to reach theevacuation locus would be significant. In such cases theoutcome is actually
than if the patient had not undergoneevacuation.New techniques such as MRI with gadolinium contrastand stereotactic surgery that would allow rapid evacuationof hematomas without the collateral neurologicdamage and rebleeding risk of transcranial surgery arecurrently being evaluated; however, they are not yet routinelyavailable.
Outcome of this case.
The patient's consciousnessslowly improved, and he was awake after 72 hours; by day5, he was able to be extubated. He was placed in a rehabilitationunit, and his hypertension is currently being successfullycontrolled (105/78 mm Hg) with a combinationof an ACE inhibitor and a β-blocker. However, his prognosisfor neurologic recovery and even for 1-year survival remainsguarded.
Quershi AI, Tuhrim S, Broderick TP, et al. Spontaneous intracerebral hemorrhage.
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Zhu XL, Chan MS, Poon WS. Spontaneous intracranial hemorrhage: whichpatients need diagnostic cerebral angiography? A prospective study of 206 casesand review of the literature.
Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safeand effective? A systematic review of case series and randomized trials.