A Case Report in Hemorrhagic Stroke: A Complex Disease Process and Requirement for a Multimodal Treatment Approach.

Open Access Case Report DOI: 10.7759/cureus.2976 A Case Report in Hemorrhagic Stroke: A Complex Disease Process and Requirement for a Multimodal Treatment Approach Brain D. Sindelar 1 , Vimal Patel 2 , Shakeel Chowdhry 3 , Julian E. Bailes 2 1. Department of Neurosurgery, University of Florida 2. Northshore Neurological Institute, NorthShore University Health System, University of Chicago Pritzker School of Medicine 3. Neurosurgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine  Corresponding author: Julian E. Bailes, Disclosures can be found in Additional Information at the end of the article Abstract Intracerebral hemorrhage (ICH) with or without intraventricular hemorrhage (IVH) is a highly morbid disease process due to the mass effect and secondary injury that occurs upon the surrounding brain. Historically, surgical evacuation has failed to demonstrate improved outcomes in comparison to standard medical therapy likely due to the significant brain trauma when accessing the clot. Recent minimally invasive techniques have proposed a way to improve outcomes by reducing this injury. We report here a 62-year-old male with ICH and IVH with acute neurological deterioration due to hydrocephalus was found to have no improvement following external ventricular drainage. A repeat non-contrasted computed tomography (CT) head was obtained which demonstrated the worsening mass effect from peri-hematoma edema. Surgical intervention was employed that uses a variety of techniques (endoscopic and exoscopic visualization, stereotactic trans-sulcal approach and side cutting aspiration, and intraventricular thrombolytic therapy) to reduce cerebral trauma while effectively removing both ICH and IVH. The surgical intervention reduces the mass effect and associated secondary injury, lessens the likelihood of shunt placement and length of stay, and improves long-term morbidity. We conclude that the effectiveness of surgical management of ICH could potentially be improved by employing a multifaceted approach to address the different characteristics of the hemorrhagic stroke. Categories: Neurology, Neurosurgery Keywords: intracranial hemorrhages, cerebral hemorrhage, hematoma, thrombolytic therapy, stroke Introduction Received 04/20/2018 Review began 05/01/2018 Review ended 06/29/2018 Published 07/13/2018 © Copyright 2018 Sindelar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., Minimally invasive surgical interventions for evacuation of intracerebral hemorrhage (ICH) and/or intraventricular hemorrhage (IVH) (in order to remove mass effect, prevent secondary injury, and potentially reduce morbidity/mortality) have demonstrated a range of published clinical outcomes, and therefore the use of one specific or any surgical modality is greatly contested. Here, we will present our management of a particular case of significant ICH with IVH with the purpose of transitioning the dialogue away from choosing a single medical or specific surgical approach to suggesting a multifaceted treatment tactic of ICH in order to reduce this devastating affliction. which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Case Presentation A 62-year-old male with a history of gastroesophageal reflux and deep vein How to cite this article Sindelar B D, Patel V, Chowdhry S, et al. (July 13, 2018) A Case Report in Hemorrhagic Stroke: A Complex Disease Process and Requirement for a Multimodal Treatment Approach. Cureus 10(7): e2976. DOI 10.7759/cureus.2976 thrombosis/pulmonary embolism, developed sudden onset headache prior to his scheduled Nissen fundoplication. The patient presented to an outside hospital neurologically intact, but due to intractable symptoms, a non-contrasted head computed tomography (CT) was ordered which was significant for a right-sided caudate ICH with ventricular extension but without hydrocephalus (Figure 1A) (ICH score 1). Of note, the patient’s coagulation labs were within normal range. En route to our hospital, the patient declined dramatically requiring intubation upon arrival. Repeat imaging was significant for expansion of the ICH with worsening of the IVH and associated hydrocephalus (Figure 1B). The patient was localizing on the right upper extremity and withdrawing in the left upper extremity and bilateral lower extremities to noxious stimuli (GCS 7t, ICH score 2). An external ventricular drain (EVD) was placed and the patient was admitted to the intensive care unit (ICU). Vascular imaging was negative for underlying malformations. A repeat CT head six hours post EVD placement demonstrated a collapsed ventricle secondary to cerebrospinal fluid (CSF) drainage, but the progression of perihematoma edema and midline shift (Figure 2). With increasing mass effect and failure of neurological improvement with CSF drainage, it was decided to take the patient to the operating room for ICH evacuation. FIGURE 1: Head computed tomography (CT) pre- and postadmission. A) Right caudate intracerebral hemorrhage (ICH) (17 cm3) (black arrow) with ventricular extension (red arrow) but without hydrocephalus. B) Repeat CT head significant for slight increased size of ICH (21 cm 3) (black arrow) with greater intraventricular hemorrhage (red arrow), casting of the right lateral and third ventricles, and hydrocephalus (blue arrow). 2018 Sindelar et al. Cureus 10(7): e2976. DOI 10.7759/cureus.2976 2 of 6 FIGURE 2: Repeat computed tomography (CT) head six hours (following morning) after presentation. Increased size of the intracerebral hemorrhage (23 cm 3), a collapsed left lateral ventricle (red arrow) secondary to cerebrospinal fluid drainage, entrapment of the left temporal horn, and peri-hematoma edema with 6.5 mm of midline shift. Following anesthetization, a 5 cm curvilinear right frontal incision was made behind the hairline. A 4 cm craniotomy was performed followed by identification of the posterior aspect of the right frontal superior sulcus, and then stereotactic trans-sulcal introduction of a 75 mm sheath and obturator (BrainPath, NICO Corp, Indianapolis, Indiana). Under exoscope magnification, the inferior depth of the hematoma was evacuated with gentle irrigation and suction. A small opening into the right lateral ventricle was identified, and a straight rigid endoscope was used to atraumatically enter the ventricle for further ventricular clot evacuation and irrigation. The endoscope was removed and the trans-sulcal port was slightly retracted in successive fashion to deliver more of the frontal ICH into view. With the use of suction, irrigation, and a side cutting resection device (Myriad, NICO Corp, Indianapolis, Indiana), the remainder of parenchymal hematoma was extracted. A post-operative head CT showed near complete removal of the ICH and IVH from the right lateral ventricle but with re (...truncated)