Pain Management

Tomaz Velnar, MD, PhD is a Neurosurgeon and Assistant Professor at Ljubljana Medical Centre. He is also active in research, cooperating regularly with the other two authors. They have started a multicentre study of vitamin D deficiency among older people.

Spontaneous intracerebral haemorrhage has a high disability and mortality rate. In cases, when surgery is needed, minimally invasive approach is ecommended. A 59-year old patient was admitted due to progressive left sided arm and leg weakness. The neurological status started to deteriorate quickly. A computed tomography (CT) of the head revealed an ICH of 7 cm in diameter with haematocephalus and cerebral oedema. The CT angiography was negative, classifying the haematoma as a primary one. Coagulation and aggregation values were deranged as a result of liver failure. The international normalised ratio (INR) and prothrombine time (PT) were lowered to 1.56 and 0.47 respectively. The platelet count was 33 and the platelet function tests were completely disturbed. Injections of fresh frozen plasma, recombinant coagulation factor VIIa, protrombin complex, vitamin K and platelet plasma were applied. As a result of extensive intracerebral bleeding and consciousness decline, surgery was recommended despite unfavourable laboratory results. A minimally invasive approach was chosen for the ICH removal. A burr hole of 1 cm in diameter was made in the right temporal area. Under the microscope, the liquefied blood was evacuated with aspirator and bipolar. The ICP values remained normal during the course of treatment. The control CT scan showed successfully evacuated haematoma and normal width of the ventricles. The sedation was gradually discontinued after a week. The patient was awake with persistent left sided haemiplegia. In case of patient with numerous risk factors and imminent operation, minimally invasive surgery for intracerebral haematoma is warranted.