SPECIFICS OF ANESTHESIA IN A PATIENT WITH INTRACEREBRAL HEMORRHAGE – CASE REPORT

Abstract

Intracerebral hemorrhage (ICH) is a subtype of stroke whereby a pathological accumulation of blood (hematoma) is formed within the brain parenchyma. The hematoma compresses adjacent brain tissue, causing neuronal dysfunction that depends on growth rate, size, localization of hematoma, and intracranial pressure. ICH is at high risk for patients' lives due to the urgency of the condition, brain damage, with a mortality of about 60 – 65%, and 50% of survivors with a permanent disability. The aim of this paper is to show that timely diagnosis, urgent surgical treatment, adequate anesthesia and postoperative intensive care are of great importance for the outcome of the patients. Most general anesthetics have a beneficial effect on cerebral metabolism, blood flow, cerebrospinal fluid (CSF) dynamics, and intracranial volume and pressure.
Material and methods: Patient, 50 years old, admitted to the emergency department, in severe general condition, soporous, with normal breathing condition. The performed laboratory tests were in normal limit values. CT scan of the brain presented a massive intracerebral hemorrhage with penetration into the ventricular system. The patient was immediately admitted to the intensive care unit, where after the deterioration of the condition, Glasgow coma scale 4, mydriasis, occurrence of decerebration movements and respiratory depression, was intubated and transferred to the operating room. Before and intraoperative we had tachycardia and hypertension, so it was treated with antihypertensive and antiarrhythmic therapy. General anesthesia was performed with Propofol, Fentanyl, Rocuronium and Sevoflurane. Intraoperative we had massive IC bleeding and gave 1 gram of Tranexamic acid as well as transfusion of two units of blood and two units of fresh frozen plasma. Postoperatively he was in intensive care unit without satisfactory self-breathing on mechanical ventilation (IPPV), sedated with Midazolam and Fentanyl. In the ICU appropriate antihypertensive, anti-edematous, antibiotic and physical therapy was administered. A central venous catheter and nasogastric tube were placed. After 10 days, a tracheotomy was performed, still on mechanical ventilation and a change of breathing regime depending on the occasional improvements and deterioration. After two months, the condition improves, with satisfactory own breathing, spontaneous closure of the tracheostomy, so we sent him in a stable general condition for home treatment.
Conclusion: The development of modern diagnostic techniques, anesthesia, monitoring, surgical methods, postoperative treatment, care and rehabilitation has a positive outcome in neurosurgical patients with cerebral hemorrhage. In neurosurgery, anesthesia techniques must be modified in the presence of intracranial hypertension and impaired cerebral perfusion to protect brain tissue.