Case Study on Left Gangliocapsular Intracranial Hemorrhage with Cranioplasty

Mercy Ezhil Rani

Clinical Educator, Kauvery Hospital, Hosur, Tamil Nadu

Introduction

A left gangliocapsular bleed typically refers to a hemorrhagic stroke or bleeding in the basal ganglia and the adjacent internal capsule on the left side of the brain. This condition is often caused by uncontrolled hypertension, trauma, or other underlying conditions like vascular malformations.

Incidence

A left gangliocapsular bleed is typically a type of intracerebral hemorrhage, which occurs in the basal ganglia and internal capsule. The incidence of such bleeding is associated with risk factors like hypertension, cerebral amyloid angiopathy, and anticoagulant therapy. Intracerebral hemorrhages themselves account for approximately 10-15% of all strokes globally, with basal ganglia being one of the most common sites due to the vulnerability of small perforating arteries.

Present Complaints:

A 24-year patient was brought to the ER with complaints of sudden onset of giddiness, left-sided weakness, slurring of speech, and vomiting. On arrival, his GCS was E1V1M4, pupils were bilateral 2 mm non-reactive to light, so he was intubated and placed on mechanical ventilation.

Past Medical History:

Known case of hypertension for 3 months, on regular medication.

Investigations:

InvestigationsOn admissionIntra operative At discharge
TC18010/cu.mm8850/cumm
Platelet316000/cu.mm314000/cu.mm
Urea19mg/dl
Creatinine0.6mg/dl
Sr.Sodium137 mmol/L135 mmol/L142mmol/L
pH7.337.55
PO2239mmHg140mmHg
PCO2 47mmHg24mmHg
HCO324.8 mmol/L21.0 mmol/L
Hb15.3g/dl13.2mg/dl
Sr.K+3 mmol/L5.1mmol/L4.1 mmol/L

ECG & ECHO: No RWMA, LV EF: 55%, Trivial TR

CT Brain

  • Large ICH in the left temporoparietal region with mass effect
  • Midline shift
  • Diffuse cerebral edema

Diagnosis:

  • Left Gangliocapsular bleed (ICH) with mass effect and IVH with obstructive hydrocephalus
  • Systemic Hypertension

Case Presentation:

Day 1

The patient underwent an emergency Left Frontotemporoparietal (FTP) decompressive craniectomy with evacuation of ICH and tracheostomy under general anesthesia. Postoperative imaging revealed residual ICH in the Left Gangliocapsular (GC) region, brain parenchyma herniation into the calvarial defect, and squashing of the left lateral ventricle with progressive dilation of the lateral ventricles and temporal horns.

Day 2
To manage hydrocephalus, a Right Kocher point External Ventricular Drain (EVD) was placed under general anesthesia. Continuous drainage was initiated, with regular monitoring of neurological and physiological parameters.

Day 3
The patient’s GCS improved to E2VTM5. However, persistent fever spikes prompted tracheal culture and sensitivity testing, while high blood pressure necessitated escalated antihypertensive therapy as per physician advice.

Day 4
Repeat CT imaging revealed re-bleeding at the evacuated ICH site, along with midline shift and mass effect. The patient underwent re-exploration and evacuation of ICH under general anesthesia. Postoperative care included anti-edema measures, neuroprotective therapies, and aggressive blood pressure control.

Day 5

Post-surgery, the patient’s GCS remained at E1VTM5, with noted right extremity weakness. Laboratory findings indicated a hemoglobin level of 7.9 g/dL, prompting transfusion of 1 pint of packed red blood cells (PRBC). Imaging showed decreased mass effect, resolution of midline shift, and no hydrocephalus. The EVD was removed following clinical improvement.

Day 6
The patient’s GCS was E1VTM4. CT imaging and cerebral angiogram confirmed no vascular malformations, decreased midline shift, brainstem edema, and intraventricular hemorrhage (IVH) without hydrocephalus. The patient was successfully weaned from the ventilator to a T-piece.

Infection Monitoring and Treatment:

  • On 10.24, tracheal and urine cultures showed no growth. Fever spike settled.
  • On 28.10.24, intermittent fever spikes prompted repeat tracheal culture, which revealed Acinetobacter. Antibiotics were continued, and fever spikes gradually reduced.

Medical Management:

The patient was managed with:

  • IV Antibiotics – Inj. Xone 2gm IV given twice a day for 5 days.
  • Antiepileptics – Inj. Levipil 1 gm IV given twice a day for 8days.
  • Antihypertensives – Tab. Nicardia refrad 20mg RT twice a day, Tab. Prozopill XL 5mg twice a day
  • Ulceroprotectives – Inj. Pan – 40mg IV once a day
  • Analgesics
  • RT Feed 200ml every 2nd hourly
  • Tracheostomy care in each shift
  • DVT stockings applied.
  • Chest and limb physiotherapy

Rehabilitation & Discharge:

  • On 10.24, GCS improved to E3VTM5. Patient was shifted to the ward with continued physiotherapy and supportive care.
  • On 01.11.24, GCS E4VTM5. Sodium levels normalized.

On 27.01.2025, the patient was readmitted for the Left FrontoTemporo Parietal Cranioplasty procedure. No acute complaints were reported upon arrival.

Preoperative Evaluation:

CT Brain Findings:

  • Old gliosis with encephalomalacia in the left temporal, left capsulo-ganglionic, and left frontoparietal regions.
  • Postoperative changes in the left FTP skull vault.
  • No midline shift or mass effect.
  • Postoperative burr hole changes in the right frontal region.
  • Patient was planned for Left FTP cranioplastyafter obtaining informed written consent and pre-anesthetic fitness clearance.

Surgical Procedure:

  • On 28.01.2025, the patient underwent Left FTP cranioplastyusing an autologous bone graft under general anesthesia.

Postoperative Course:

Immediate Postoperative Monitoring:

  • Patient was shifted to ICU for observation.

Postoperative CT Brain:

  • Left FTP postoperative changes (+).
  • Bone graft in situ.
  • Left FTP gliotic changes (+).
  • No evidence of bleeding
  • Ventricles midline.
  • Drain in situ.

Postoperative Day 1 (POD-1):

  • GCS: E4VaphonicM6.
  • Pupils: B/L 3mm, reactive to light (RTL).
  • Right-sided paucity (+).
  • Wound healthy, dressing done.
  • Postoperative hemoglobin: 12.0 g/dL.
  • Patient symptomatically better and shifted to the ward for further management.

Postoperative Day 2 (POD-2):

  • GCS: E4VaphonicM6.
  • Pupils: B/L 3mm, RTL.
  • Wound healthy.
  • Foley’s catheter removed, and patient voided normally.

Postoperative Day 3 (POD-3):

  • GCS: E4VaphonicM6.
  • Drain tube removed, dressing done, wound healthy.

Discharge and follow-up:

The patient was symptomatically better:

Voided normally.

Tolerates oral diet.

  • BP: 120/90 mmHg
  • PR: 80 bpm
  • SpO₂: 99%
  • GCS: E4VaphonicM6
  • Pupils: B/L 3mm, reacting to light
  • Systemic Examination:
  • CVS: S1S2 heard, no murmur.
  • RS: Bilateral air entry present
  • DEM: Positive

Health Education

1.Wound Care:

  • Keep the surgical site clean and dry.
  • Change dressings as instructed by the healthcare team.
  • Watch for signs of infection (redness, swelling, discharge, or fever) and report immediately.

2. Activity and Mobility:

  • Avoid strenuous activities or heavy lifting for at least 4-6 weeks.
  • Gradually increase physical activity as recommended by the physiotherapist.
  • Avoid bending, straining, or sudden head movements.

3. Head Protection:

  • Avoid trauma to the head.
  • Use a protective helmet if advised until the surgical site is fully healed.

4. Nutrition:

  • Maintain a balanced diet rich in protein, vitamins, and minerals to promote wound healing.
  • Stay hydrated and avoid alcohol or smoking.

5. Warning Signs to Report:

  • Persistent headache, vomiting, or drowsiness.
  • Seizures or unusual behavior.
  • Weaknesses, numbness, or difficulty speaking.
  • Signs of infection (fever, redness, or discharge from the wound).
  • Any fluid leakage from the surgical site.

6. Home Care and Lifestyle Modifications:

  • Educate on the importance of a safe home environment to prevent fall or injury.
  • Emphasize the importance of rest and stress management.
  • Provide guidance on resuming work or daily activities based on the doctor’s advice.

7. Counseling and Support:

  • Address any emotional or psychological concerns regarding the surgery and recovery.
  • Encourage participation in rehabilitation programs, if needed.

 

 

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment