Mr John, a 48 years old gentleman, presented to the emergency department with complaints of an episode of generalized, tonic clonic seizure which lasted for 15 minutes and loss of consciousness. He was brought to the hospital within half an hour of the episode. He had no prior history of seizures, neurological problems or any episode of loss of consciousness. In the past few days, he complained of constant headache and some visual disturbance.
On examination in the emergency room, he had a GCS of 8, an extensor response on the left side and papilledema in the left eye. His oxygen saturation was 86%, blood pressure was 190/110 and heart rate was 69/min. Rest of his examination was unremarkable.
He was immediately intubated and a CT scan was done. The CT scan showed massive intracranial bleed on the left side and a left frontoparietal mass which was creating midline shift towards the right. A diagnosis of primary brain tumor with an associated intracranial bleed was made.
The patient was taken to the operating room and a decompressive craniotomy was done. Later on, a second surgery for debulking the tumor was performed. Mr John stayed in the neurological intensive care unit (ICU) for ten days. During his stay in the ICU, he was under neuroanesthesia and his ICP and cardiac parameters were vigilantly controlled using general measures (head elevation, hyperventilation and hypothermia) and drugs including mannitol, steroids, and antihypertensive medications.
As he started to recover, he was shifted from the ICU and remained admitted in the hospital for about 15 days. At the time of discharge, he still had weakness on the right side of his body and gait disturbance.
During follow-up in clinic, his right sided weakness improved but a significant improvement in his gait was not seen.