ICH, Right Midbrain

H&P

• HPI:
  • Presented to ED
  • Sudden onset of left hemifacial anesthesia, diplopia
• PE:
  • GCS 15
  • PERRLA
  • Upward and leftward gaze palsy with internuclear opthalmoplegia
  • Diminished sensation on left V1-V3
  • Tongue midline, uvula/palate symmetric, no dysphagia
  • Full strength throughout, SITLT, (-) pronator drift/hyperreflexia/clonus

Imaging

CT Head without Contrast - Axial, Coronal, and Sagittal

Axial Brain MRI without Contrast - DWI/ADC/FLAIR/SWI

Axial Brain MRI without Contrast - T1WI and T2WI

Brain MRI with Contrast - T1WI, Axial, Coronal, and Sagittal

Hospital Course

• ICU admission with hourly neuro-checks
• Improved neurological function
• Repeat CT head stable ICH
• Transferred to floor on HD1
• Discharged home on HD2

Follow-Up Brain MRI (2 months)

Axial Brain MRI without Contrast - DWI/ADC/FLAIR/SWI

Axial Brian MRI without Contrast - T1WI and T2WI

Brain MRI with Contrast - T1WI, Axial, Coronal, and Sagittal

Follow-Up Clinic (2.5 months)

• Stopped lisdexamfetamine
• Left facial anesthesia resolved
• Horizontal diplopia resolved
• Vertical diplopia persisted
• Otherwise no deficits
• PE: PERRLA, EOMI, CN II-XII intact
• #todo Follow up brain MRI with and without contrast in 6 months

Discussion

• Most likely diagnosis is hypertensive ICH due to the side effect of lisdexamfetamine
• No evidence of cavernous malformation on brain MRI