Neurology · Year 3 · from Neurology

Case 3: Intracerebral Hemorrhage with Herniation

Patient Demographics

  • Age: 65 years
  • Sex: Male
  • Occupation: Retired factory worker

Chief Complaint

"He suddenly collapsed and won't wake up."

History of Present Illness

Patient was watching television when he suddenly complained of the worst headache of his life, then became unresponsive within minutes. Family called 911. He has a history of poorly controlled hypertension (often runs 180s/100s systolic) and medication non-compliance. He takes amlodipine and lisinopril "sometimes."

Neurological Examination Findings

Mental Status:

  • GCS: 6 (E1 V2 M3)
  • No eye opening, incomprehensible sounds, withdraws to pain
  • Not following commands

Cranial Nerves:

  • Left pupil: 6 mm, fixed, non-reactive (concerning for uncal herniation)
  • Right pupil: 3 mm, reactive
  • Corneal reflexes: Absent left, present right
  • No oculocephalic reflex (doll's eyes absent)

Motor Examination:

  • Decorticate posturing on left with stimulation
  • Right side: Extensor posturing
  • No spontaneous movement

Sensory Examination:

  • Withdraws to central pain only

Reflexes:

  • 3+ bilateral
  • Bilateral Babinski positive

Other:

  • Blood pressure: 220/120 mmHg
  • Signs of increased ICP: Cushing reflex (hypertension, bradycardia)

Localization

Lesion Location: Left basal ganglia/putaminal hemorrhage with mass effect

  • Contralateral hemiplegia (left internal capsule/basal ganglia)
  • Fixed dilated left pupil (uncal herniation compressing CN III)
  • Decreased consciousness (ascending reticular activating system compression)
  • Bilateral extensor posturing (brainstem dysfunction)

Neuro Workup

  • CT Head without contrast: Large left putaminal hemorrhage (60 mL), 12 mm midline shift, effacement of left lateral ventricle, early uncal herniation
  • ICH Score: 4 (poor prognosis)
  • Labs: INR 1.0, platelets 180K, Cr 1.8
  • CTA: No underlying vascular malformation

Diagnosis

Hypertensive left putaminal intracerebral hemorrhage with uncal herniation

Management

Emergent Interventions:

  1. Secure airway - intubation for GCS <8
  2. Blood pressure reduction: IV nicardipine to target SBP 140-160
  3. Hyperosmolar therapy: Mannitol 1 g/kg IV, then q6h; or hypertonic saline
  4. Head of bed 30 degrees
  5. Neurosurgery consultation for possible hematoma evacuation

ICU Management:

  1. External ventricular drain (EVD) placement for ICP monitoring and CSF drainage
  2. Goal ICP <20 mmHg, CPP >60 mmHg
  3. Seizure prophylaxis with levetiracetam
  4. Reversal agents if on anticoagulation (not applicable here)
  5. Fever control - normothermia

Goals of Care:

  1. Family meeting regarding prognosis (ICH score 4 = ~97% mortality at 30 days)
  2. Discussion of comfort measures vs. aggressive intervention
  3. Palliative care consultation

Clinical Image

Image Description: Non-contrast CT head demonstrating a large left putaminal hemorrhage with significant mass effect, midline shift, and compression of the left lateral ventricle.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/hypertensive-basal-ganglia-haemorrhage

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