CASE PRESENTATION
A 39 –years- male patient presented to our institution with the history of acute onset of weakness of the right side of the body, deviation of angle of the mouth to left side, generalized stiffness of the body, unable to speak and urinary incontinence for which he was evaluated and managed conservatively in another center. His medical, surgical and drug history was unremarkable. Family history was irrelevant and history of trauma was trivial.
On retrospective survey, when he presented to the ER in the other center, his pulse rate was 98 bpm, blood pressure was 200/100 mm of Hg, Glasgow coma scale (GCS) was E4 V2 M6, pupils were bilateral equal and reactive to light. Further neurological examination revealed a decreased sensation over right side of the body with motor power in the Right upper and lower limbs was 0/5 and 5/5 in left upper and lower limbs. His deep tendon reflexes were absent on the right side but preserved on the left side. Similarly, the plantar reflex on the right side was extensor and flexor on the left.
Laboratory parameters were within normal limit. CT scan of head revealed hyper dense lesion involving bilateral basal ganglia suggestive of blood with volume of 28 cc in left and 13 cc in right (Figure 1). He was then admitted in an ICU and managed conservatively. There was gradual improvement in the condition of patient, he was then shifted to ward and after 9 days of admission, he was discharged and he presented to our center for further management and advice.
At presentation to our center, GCS: E4 V4 M6, Pupils: Bilateral 2 mm and reactive to light, Sensation was decreased over right half of the body. Motor power in the RUL/RLL was 4+/5 and in LUL/LLL was 5/5, deep tendon reflexes were decreased over right side.
CT head and CTA was repeated. CT head revealed resolving hematoma (Figure 2). CTA was negative for intracranial aneurysms, vascular malformations, vasospasm or cerebral venous thrombosis (Figure 3).
When the patient presented to our facility six months following the first bleed, he was fully oriented to time, location, and person, with motor power 5/5 in all four limbs and very little slurring of speech and enhanced emotional drive. He is now able to carry out his daily tasks alone and has returned to his farm. We took another CT scan of the head, which revealed a resolving hematoma. (Figure: 4).