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Case of the Month

Welcome to CNS Case of the Month Section.
The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.

We are always open to suggestions, and if you have a case or questions that you would like to have presented, please submit them to: info@1cns.org

Brian L. Hoh, MD
University of Florida
Ashok R. Asthagiri, MD
Associate Professor
Department of Neurological Surgery
University of Virginia
Maryam Rahman, MD MS
Assistant Professor
Department of Neurosurgery
University of Florida
Alexander A. Khalessi MD, MS
University of California San Diego
Wilson Z. Ray, MD
Assistant Professor in Neurosurgery
Department of Neurological Surgery
Washington University School of Medicine
Edward R. Smith, MD
Director, Pediatric Cerebrovascular Surgery
Department of Neurosurgery
Children's Hospital Boston / Harvard Medical School
Sameer Sheth, MD, PhD
Assistant Professor of Neurosurgery
Columbia University Medical Center
New York Presbyterian Hospital
July 2014: Acute Hemiplegia in a 53-year-old


  • 53-year-old
  • Acute onset obtundation, vomiting and left hemiplegia
  • Intubated in the Emergency Department
  • Diagnosis of Spontaneous ICH established
  • Vascular imaging ruled out occult vascular imaging
  • Contralateral EVD placed and MR Imaging Obtained

Figure 1: Axial FLAIR and Coronal T2W MRI
[Click to view larger image]
Click image to view larger picture.

1. The current state of the published literature most supports which of the following treatment strategies for ICH > 1 cm from any cortical surface:
    a. Conservative management
    b. Decompressive craniectomy with dural opening
    c. Decompressive craniectomy with clot evacuation
    d. Endoscopic evacuation
    e. Partial endoscopic evacuation with catheter placement and serial administration of tPA
2. Were an endoscopic approach entertained, which of the following represents the most proven trajectory for this clot distribution?
    a. Interhemispheric transcallosal
    b. Supraorbital transcortical via middle frontal gyrus
    c. Transcortical via occipital pole
    d. Transcortical via inferior parietal lobule

Figure 2: Post Operative CT
[Click to view larger image]
Click image to view larger picture.

3. Which of the following may increase the likelihood of procedural benefit?
    a. Hematoma volume > 30 cc
    b. Adjunctive administration of Factor VII
    c. Extension to within 1 cm of a cortical surface
    d. Age greater than 80
    e. Presenting GCS < 8
4. In early phases of MISTIE-ICES Trial, which of the following corresponded with improved procedural outcome?
    a. Presence of intraventricular hemorrhage
    b. Procedural Reduction of hematoma volume < 15 cc
    c. Endoscopic trajectory perpendicular to long axis of the clot
    d. Time to surgical evacuation
5. Which of the following describes you?
    a.   Resident/fellow
    b.   Private practice
    c.   Academics
6. I practice in one of the following locations.
    a.   I practice in one of the following states: WA, OR, CA, AK, HI
    b.   I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
    c.   I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
    d.   I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
    e.   I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
    f.   I practice in Mexico or Canada
    g.   I practice in South America
    h.   I practice in Europe
    i.   I practice in Asia
    j.   I practice in Australia/Pacific Rim
    k.   I practice in Africa

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Pubmed References
  • Hanley, Daniel. “MISTIE II: 365 Day Outcome and Cost Benefit.” RO1NS046309

  • Mendelow et al for STICH II Invesitgators. “Early Surgery versus Initial Conservative Treatment in patients with spontaneous supratentorial lobar intracerebral hematomas (STICH II)” Lancet 2013; 382: pp. 397-408

  • Picture of initial clot interface on peel away sheath introduction
  • Two illustrative videos showing clot evacuation and progressive cavity collapse

Figure 3
[Click to view larger image]
Click image to view larger picture.