CC: Basal ganglia ICH
HPI: 33 y.o. female patient with hx of Moya Moya s/p Right STA-MCA onlay bypass in 20/18
who presents after being found down. LKN of 0300. Her mother found her on the floor at 1000
with L hemiplegia. EMS was called.
Work up in ED reveled CT head demonstrated a large R basal ganglia hemorrhage with mass
effect, IVH, as well as trace blood in the R vent 3 and 4. Reported episode of systemic
hypertonia - resolved after 10 seconds, unclear if seizure. She was arousable but having
episodes of being sonorous and had significant dysarthria. She required aggressive sternal rub
to arouse.
In the ED, she was given keppra as well as mannitol. Due to her inability to protect to airway
and declining mental status, she was emergently intubated.
Time of onset: 0300 LKN
PMH:
Anxiety
Asthma
Depression
Hx of idney stones
Moyamoya
Narcolepsy
PSH:
Cranial angio - 12/2018
Bilat cerebral sarotid angio
Encephalo-Myo-Synangiosis (indirect cerebral bypass)
R craini 6/2018
Home Medications:
Lipitor 10 mg daily
B vit daily
Co enzyme Q10
Gabapentin 300mg/QHS 100mg/QAM
Inpatient meds:
Keppra 1000 BID
Mannitol 75 x 1
Continuous Infusions:
PRN Meds:
Allergies: NKDA
Family History: None of relevance to acute dx / CC of concern
ROS: Unable to obtain due to clinical condition, (intubation, encephalopathic)
PHYSICAL EXAM
Neuro:
GCS: E 2 V 2 M 6
Higher cortical function:
Eyes open to noxious stim, requires repeated stimulation to arouse, answered name, age,
hospital, would not participate in any further language testing. L sided neglect. Intermittently
followed commands on the R side.
Cranial nerves: Pupils equally reactive to light and accommodation, sluggish. Visual fields no
blink to threat on the L side. R gaze deviation, no L gaze. L facial droop. Speech very dysarthric.
Motor/Sensory: Normal bulk and decreased L-sided tone. Drift on the R side. L UE extension, L
LE triple flex in response to noxious stim.
Reflexes: L toe extensor response to plantar stimulation.
Coordination: unable to assess due to encephalopathy
Gait: deferred
NIHSS:
1a. Level of consciousness: 2
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 2
3. Visual: 2
4. Facial palsy: 2
5a. Motor arm (left):3
5b. Motor arm (right): 1
6a. Motor leg (left): 3
6b. Motor leg (right): 1
7. Limb ataxia: 0
8. Sensory: 1
9. Best language: 1
10. Dysarthria: 2
11. Extinction and inattention:2
Total: 22
Remaining systems:
Temp 38.1; BP 138/75; HR 79; RR 22, Sats 97 % RA
General: Ill appearing, obese
HEENT: normocephalic, atraumatic, oropharynx pink and moist, dentition intact
Neck: supple
CV: +S1 +S2, RRR, no murmurs, rubs or clicks; symmetric, regular pulses
Lungs: clear throughout to auscultation, sonorous at times
Abd: soft, nontender, normal bowel sounds
Ext: (-) C/C/E or deformity
Skin: warm, dry, intact joints without deformities
PLAN/ASSESSMENT:
33 y.o. female patient presented with L sided weakness, exam findings of L HH,
encephalopathy, L hemiplegia, CT head with basal ganglia ICH. Etiology is likely related to Moya
Moya given that her surgery was on the R side in the past and no evidence of malignant HTN at
presentation.
Neurologic:
ICH, IVH, Acute metabolic encephalopathy, Cerebral edema, Compression of the brain, Moya
Moya, s/p EDAMS, Narcolepsy, Depression, anxiety
CT at admit shows 7.6 cm parenchymal hematoma centered in the right putamen/posterior
frontal lobe with associated local mass effect, 6 mm right to left shift, and
intraventricular hemorrhage as detailed above. No clear tonsillar herniation or
uncal herniation present
CTA:1. Chronic high-grade stenosis versus occlusion of the distal right M1 segment
with ipsilateral lenticulostriate and PCA collaterals as previously discussed as
well as mild diffusely decreased perfusion in the right MCA territory, similar
to the prior. Small STA branch serving the STA-MCA anastomosis does not clearly
show filling on CTA; consider conventional angiography.
2. Otherwise normal intracranial vasculature
Plan:
- Admit to NCCU
- Case discussed with MDs, plan for OR for hematoma evacuation and EVD placement – going
down within hours
- Anticoagulation reversal: NA
- Hyperosmolar therapy: s/p mannitol x1, will determine need for additional hypertonics after
OR
- Neuro checks every 2 hours for potential neuro decline related to rebleeding, hematoma
expansion, or hydrocephalus
- PT/OT/SLP to evaluate and treat when appropriate
- keppra 500mg q 12 hrs
- restart lamictal, gabapentin after enteral access
- hold ritalin and provigil for now
- hold cymbalta (unable to go down OG tube)
CV: NSR, HLD
Plan:
-Continue hemodynamic monitoring.
- Blood pressure management: Keep SBP <160 with labetalol or nicardipine drip as needed.
- continue atorvastatin
Respiratory: Ventilator dependent
Data:
CXR: EET at appropriate place
Diagnoses:
Acute respiratory failure due to inability to protect airway
Plan:
- Ready to wean: No
- Ready to extubate: No
- HOB >30 degrees
- Maintain oxygen saturations > 92%
- VAP prevention protocol
F/E/Renal/GU: HypokalemiaHx of kidney stones
K
3.8
CL
107
CO2 19*
BUN 25*
CREA 0.93
CALCIUM
10.1
Plan:
- electrolyte replacement protocols
- IVF: bolus with mannitol (x1 complete), continue IVF
Endocrine: Risk of poorly controlled blood sugars r/t critical illness
Plan:
-Glucose Goal 90-180, correction factor insulin
GI/Nutrition:
Plan:
- prevent constipation/avoid straining, Bowel care: prns
- antiemetics PRN
- OG tube
- swallow eval and speech when appropriate
Heme/Coags: anemia, baseline
PTT
24.9
INR
1.0
HGB 9.9*
HCT 31.5*
PLT
514*
Plan:
- type and screen completed, trend labs, transfuse if symptomatic or if hbg below 7
ID: tmax 38l.3 , WBC12.6*, Leukocytosis (most likely refractive)
Plan:
- Monitor for fever, temperature goal < 38C to prevent increased cerebral metabolic demand.
Skin: no issues
Plan:
-monitor, frequent turning and peri care
Prophylaxis: DVT: SCDs only at this time - to reassess after OR
GI: Pepcid, PRN Zofran / reglan, maintain NPO tuntil post op
Social: Mother came with to ED, will return later after going home to pick uo husband
Code status: full