Case: 35-year-old Presenting with Hemiplegia

by Roy Strowd, MD

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    00:01 In this talk, we're going to discuss the approach to intracranial hemorrhage. We'll talk about hemorrhagic strokes and other hemorrhages that can occur on the brain and how we both diagnose and manage those patients. So let's start with a brief review of the case. This is a 35-year-old presenting with hemiplegia, a 35-year-old woman with recently diagnosed hypertension, was found down unresponsive with left hemiplegia.

    00:29 She's found to have a high blood pressure of 195 systolic over 110 diastolic with a heart rate of 50 and you can see the head CT here. We see 2 cuts of this non-contrast head CT showing a hyperdense focus in the right basal ganglia. This is an area of likely hemorrhage causing this patient's left-sided symptoms. So what's the diagnosis? Is this an epidural hematoma, subdural hematoma, a subarachnoid hemorrhage, or an intraparenchymal hemorrhage? Well, it's not an epidural hematoma. Those typically appear on CT as a lens-shaped lesion in the epidural space outside of the brain and this hemorrhage is inside the brain. It's not a subarachnoid hemorrhage. Subarachnoid hemorrhage is blood that collects along the cortical surface in that subarachnoid space between the pia and subarachnoid layers of the brain. This blood cakes in layers on the outside of the brain surface and typically presents with symptoms of increased intracranial pressure. And this patient's blood is inside the brain. This is not a subarachnoid hemorrhage. It's not subdural hematoma or a subdural hemorrhage. Those present as crescent-shaped lesions, again outside the brain in the subdural space. And this patient's blood is in the brain proper. This is a classic presentation of an intraparenchymal hemorrhage or a hypertensive hemorrhage. Those are hemorrhages occurring within the brain parenchyma itself and this hemorrhage is centered in the basal ganglia, which is one of the most common locations that we see for hypertensive hemorrhages, small vessel hemorrhages from longstanding high blood pressure. So let's talk a little bit more about the steps that we go through in evaluating patients with intracranial hemorrhage.

    02:23 And I like to think of 3 steps when evaluating these patients. First, we want to figure out what type of hemorrhage it is. Second is we'll review the work-up for the causes of the intracranial or intraparenchymal hemorrhage, what's the cause. And then 3rd, we'll use the cause to determine our appropriate management. If we know what caused it, we know how to manage it. And we'll talk about ensuring that the bleeding is controlled and managing the initial hyperacute phase of the hemorrhage and then preventing propagation of bleeding.

    About the Lecture

    The lecture Case: 35-year-old Presenting with Hemiplegia by Roy Strowd, MD is from the course Stroke and Intracranial Hemorrhage.

    Included Quiz Questions

    1. Hyperdense compared to surrounding tissue
    2. Hypodense compared to surrounding tissue
    3. Isodense compared to surrounding tissue
    4. Well-demarcated lesions confined to the epidural space
    1. Identify the type of hemorrhage, complete a workup for the causes of intraparenchymal hemorrhage, determine appropriate management
    2. Identify sites of trauma, evaluate mental status, and obtain additional imaging with contrast to rule out intracranial tumors
    3. Ensure the patient's airway is protected, ensure the patient's breathing is intact, and ensure the patient's circulatory system is adequately perfusing the body
    4. Calculate Glasgow coma score, perform an echocardiogram, and evaluate for secondary causes of hypertension
    1. Intraparenchymal
    2. Subdural
    3. Epidural
    4. Subarachnoid
    5. Lacunar

    Author of lecture Case: 35-year-old Presenting with Hemiplegia

     Roy Strowd, MD

    Roy Strowd, MD

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