This document describes the case of a patient who suffered from intracerebral hemorrhage with intraventricular hemorrhage. It outlines the timeline of events including emergent extraventricular drainage for left deep white matter hemorrhage extending to the ventricle. Over subsequent days, the patient exhibited drowsy consciousness and malfunction of the external ventricular drain. A CT scan showed correct drain tube position. Later, the patient developed new onset right intraventricular hemorrhage and underwent left stereotactic aspiration and external ventricular drainage. Eventually, a ventriculoperitoneal shunt was placed. The case highlights the relationship between deep hemorrhages and intraventricular hemorrhage risk as well as the importance

1. Intracerebral
hemorrhage
Presenter: Hsu Jin-Yi

2. L’t deep white matter hemorrhage extended to ventricle
Oct. 7, 2014

3. Oct. 7, 2014
Emergent Extraventricular drainage
L’t deep white matter hemorrhage extended to ventricle

4. Oct.7, 2014
GCS: E2VTM5
SBP around 120-150

5. Oct.7, 2014
GCS: E2VTM5
SBP around 120-150
Oct.9, 2014
Drowsy consciousness
Mal-function of the EVD, 3ml in recent 3 days
GCS: E2VTM4
SBP around 130-150
=> Malfunction of the EVD,
==> Arranged brain CT to check position

6. Oct. 9, 2014
Correct position of the drain tube

7. Oct. 9, 2014
Correct position of the drain tube
Removal the EVD

8. Oct.7, 2014
GCS: E2VTM5
SBP around 120-150
Oct.9, 2014
Drowsy consciousness
Mal-function of the EVD, 3ml in recent 3 days
GCS: E2VTM4
SBP around 130-150
=> Malfunction of the EVD,
==> Arranged brain CT to check position
Oct.12, 2014
Removed endotracheal tube
E3V3M6
SBP: 140-160

9. Oct.14, 2014
Drowsy consciousness
GCS: E3V1M5
SBP around 120-150

10. Oct. 14, 2014 Oct. 9, 2014
New-onset of Right IVH

11. Oct. 14, 2014 Oct. 9, 2014
New-onset of Right IVH
L’t Sterostatic aspiration and L’t EVD

12. Oct.14, 2014
Drowsy consciousness
GCS: E3V1M5
SBP around 120-160
Oct.15, 2014
Post-OP
GCS: E3VtM5
SBP around 130-170

13. Oct.14, 2014
Drowsy consciousness
GCS: E3V1M5
SBP around 120-160
Oct.16, 2014
GCS: E2VtM4
SBP: 120-160
Mal-function of the EVD
Oct.15, 2014
Post-OP
GCS: E3VtM5
SBP around 130-170

14. Oct. 16, 2014
Correct position of the drain tube

15. Oct. 16, 2014
Correct position of the drain tube
Urokinase through the drain tube

16. Oct.20, 2014
Removed endotracheal tube
E4V2M5
SBP: 120-160

17. Oct.20, 2014
Removed endotracheal tube
E4V2M5
SBP: 120-160
Oct.30, 2014
Arranged Ventriculoperitoneal shunt

18. Final diagnosis
L’t deep white matter intracerebral
hemorrhage with L’t intraventricular
hemorrhage s/p EVD, followed by right
frontal ICH and right IVH s/p stereostatic
aspiration and EVD s/p VP shunt

19. Intracerebral hemorrhage with
intraventricular hemorrhage

20. Question
1. Management of intracerebral hemorrhage
2. The relationship between location of the
intracerebral hemorrhage and intraventricular
hemorrhage

21. Crit Care Clin 30 (2014) 699–717
Cerebral amyloid angiopathy (CAA)

22. Crit Care Clin 30 (2014) 699–717
Cerebral amyloid angiopathy (CAA)

23. Crit Care Clin 30 (2014) 699–717

24. Crit Care Clin 30 (2014) 699–717

25. Crit Care Clin 30 (2014) 699–717
blood
pressure
reduction
cerebral
edema
management
surgical
interven-
tions
coagulo-
pathy
reversal

26. Crit Care Clin 30 (2014) 699–717
surgical
interven-
tions
ventriculo
-stomy
hematoma
evacuation

27. J Intern Med 2004; 255: 257–265.
blood
pressure
reduction

28. N Engl J Med 2013;368:2355-65

29. N Engl J Med 2013;368:2355-65

30. N Engl J Med 2013;368:2355-65

31. N Engl J Med 2013;368:2355-65

32. N Engl J Med 2013;368:2355-65

33. Neurology; 2014;83:1523–1529

34. Timing of Surgery
Cerebellar hemorrhage
Brainstem compression
Hydrocephalus from ventricular obstruction
Intraventricular hemorrhage
For patients presenting with lobar clots >30 mL
For most patients with ICH, the usefulness of
surgery is uncertain
Stroke. 2010;41:2108-2129
surgical
interven-
tions

35. Lancet 2013; 382: 397–408

36. Lancet 2013; 382: 397–408

37. Lancet 2013; 382: 397–408

38. Lancet 2013; 382: 397–408

39. Lancet 2013; 382: 397–408

40. Lancet 2013; 382: 397–408

41. Lancet 2013; 382: 397–408

42. Lancet 2013; 382: 397–408

43. Lancet 2013; 382: 397–408

44. Lancet 2013; 382: 397–408

45. Coagulopathy reversal
INR greater than 1.4 caused by warfarin
1. Fresh- frozen plasma (FFP)
2. Vitamin K
3. Prothrombin complex concentrates
4. Recombinant activated factor 7 (rFVIIa)
coagulo
-pathy
reversal
Crit Care Clin 30 (2014) 699–717

46. Cerebral edema management
Mannitol
Steroid
3% saline
Hyperventilation
cerebral
edema
managemen

47. Crit Care Clin 30 (2014) 699–717
blood
pressure
reduction
cerebral
edema
management
surgical
interven-
tions
coagulo-
pathy
reversal

48. Crit Care Med 2013; 41:1325–1331
Study deision
Nationwide, prospective cohort (N= 1,604)
Method:
Analyzed CT scan images taken within 48 hours after
stroke onset

49. Crit Care Med 2013; 41:1325–1331

50. Crit Care Med 2013; 41:1325–1331

51. Crit Care Med 2013; 41:1325–1331

52. Crit Care Med 2013; 41:1325–1331

53. Crit Care Med 2013; 41:1325–1331

54. Conclusion
High relationship with white matter lesion,
deep structure and cerebellum
No relationship with sex, age, HTN, DM.
Crit Care Med 2013; 41:1325–1331

55. Neurology; 2010;74:1502–1510

56. Lancet 2013; 382: 397–408
1. Surgical hematoma treatment
2. Reduction of hypertension
3. Reversal of coagulopathies or anticoagulants
4. Hemostatic therapy
Stroke. 2010;41:402-409

57. Back to our patient
blood
pressure
reduction
cerebral
edema
management
surgical
interven-
tions
coagulo-
pathy
reversal

58. Back to our patient
surgical
interven-
tions
ventriculo
-stomy
hematoma
evacuation

59. Back to our patient
Relative high risk of IVH by the location
Surgical intervention is essential to our
patient due to possibly obstructive
hydrocephalus due to IVH
Intensive blood pressure control ( target SBP <
140) should be considered

60. Thanks for your attention!