What is the appropriate diagnosis and management for a 45-year-old male with a history of head trauma, presenting with decreased sensorium, headache, fever, and progressive neurological deterioration, found to have bilateral temporal lobe hematomas, uncal herniation, anemia, leukocytosis, hyponatremia, hyperglycemia, and a suspected fungal infection, currently on Ceftriaxone and Gliclazide?

Diagnosis and Management

Primary Diagnosis

This patient most likely has metastatic choriocarcinoma or another highly vascular malignancy with spontaneous hemorrhagic brain metastases, complicated by bilateral uncal herniation requiring immediate neurosurgical intervention. The combination of bilateral expanding temporal lobe hematomas, multiple intramuscular masses, and progressive neurological deterioration in a 45-year-old male without adequate trauma history strongly suggests hemorrhagic metastases rather than primary traumatic injury.

Critical Immediate Management

Neurosurgical Emergency

Immediate neurosurgical consultation for bilateral craniotomy and hematoma evacuation is mandatory given bilateral uncal herniation with hematomas measuring 4.4 x 3.9 x 4.4 cm (right) and 4.8 x 4.1 x 5.8 cm (left). 1

• These hematoma sizes far exceed the threshold for surgical evacuation (>5mm thickness with >5mm midline shift), and bilateral uncal herniation represents imminent risk of death 1
• Delaying surgery while "observing" such large hematomas is inappropriate and increases mortality risk 1
• The epidural hematoma (if present) should be addressed first, followed by evacuation of the contralateral lesion through craniotomy 2
• Wide craniotomy covering the entire hematoma is essential, with preparation for decompressive craniectomy if brain swelling occurs during evacuation 1

Airway and Ventilation Management

Immediate endotracheal intubation is indicated given GCS ≤8 (drowsy, incoherent, not following commands) and bilateral uncal herniation. 3

• Maintain PaCO2 between 4.5-5.0 kPa; avoid prophylactic hyperventilation as hypocapnia causes cerebral vasoconstriction and worsens brain ischemia 3, 1
• Target PaO2 ≥13 kPa to ensure adequate cerebral oxygenation 3
• Use rapid sequence induction with maintenance of head-up tilt and hemodynamic stability 3

Blood Pressure Management

Maintain mean arterial pressure (MAP) ≥90 mmHg and systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion pressure. 3, 1

• Avoid permissive hypotension protocols designed for torso trauma, as these worsen secondary brain injury 1
• Use invasive arterial monitoring with transducer at the level of the tragus 3
• Have vasopressors (ephedrine, metaraminol, noradrenaline) immediately available 3

Fluid Management

Administer 0.9% normal saline exclusively; avoid hypotonic solutions and colloids. 1

• Hypotonic solutions like Ringer's lactate should never be used in severe head trauma 1
• Colloids should be avoided due to adverse effects on hemostasis 1

Metabolic Corrections

Aggressively correct hyponatremia (current sodium 127.64 mmol/L) with hypertonic saline, as this contributes to cerebral edema and herniation risk. 3

• Have mannitol 20% or hypertonic saline available for acute intracranial pressure management 3
• Maintain normothermia as hypothermia worsens coagulopathy 1

Diagnostic Workup

Tissue Diagnosis

Biopsy of the intramuscular masses (right arm 12.1 x 7.4 x 4.3 cm, left calf 4.7 x 5.0 x 4.5 cm) is essential to establish the primary malignancy.

• The combination of bilateral hemorrhagic brain lesions and multiple soft tissue masses strongly suggests metastatic disease
• Choriocarcinoma, melanoma, renal cell carcinoma, and thyroid carcinoma are the most common causes of hemorrhagic brain metastases
• Obtain beta-hCG, AFP, LDH, and chest/abdomen/pelvis CT to evaluate for primary tumor

Vascular Imaging

CT angiography of the head should be performed if not already done to evaluate for vascular injury or underlying vascular malformations. 3, 4

• Fractures through skull base or vascular channels warrant vascular imaging 3
• However, the bilateral nature and soft tissue masses make metastatic disease more likely than vascular injury

Antimicrobial Management

Current Antibiotic Reassessment

Ceftriaxone should be discontinued immediately given 9 days of therapy without clear bacterial infection and risk of ceftriaxone-induced encephalopathy. 5, 6

• Ceftriaxone can cause severe neurological symptoms including altered mental status, even in patients with normal renal function 5
• The urinalysis showing budding yeast cells suggests fungal rather than bacterial infection 5
• No clear source of bacterial infection has been identified to justify continued ceftriaxone 7

Antifungal Coverage

Initiate empiric antifungal therapy (fluconazole or amphotericin B) given budding yeast cells on urinalysis and persistent fever.

• The presence of budding yeast cells indicates fungal infection requiring specific antifungal treatment
• Fungal infections can cause systemic symptoms including fever and altered mental status

Post-Operative Management

Intracranial Pressure Monitoring

ICP monitoring should be instituted post-operatively to detect intracranial hypertension. 4, 1

• External ventricular drainage may be necessary for persistent intracranial hypertension 4, 1
• Target ICP <20-22 mmHg and cerebral perfusion pressure >60 mmHg 1

Seizure Prophylaxis

Administer levetiracetam for seizure prophylaxis given high risk with bilateral temporal lobe lesions. 3

• Have additional anticonvulsants (benzodiazepines, thiopentone) immediately available 3

Glycemic Control

Optimize glucose control; current FBS of 125 mg/dL on gliclazide 30 mg daily requires reassessment in the acute setting.

• Hyperglycemia worsens neurological outcomes in brain injury
• Consider insulin infusion for tighter glycemic control during acute phase

Oncologic Management

Multidisciplinary Consultation

Immediate oncology consultation is required once tissue diagnosis is established to determine systemic therapy options.

• Prognosis depends heavily on the primary tumor type and extent of metastatic disease
• Some hemorrhagic metastases (particularly choriocarcinoma) are highly chemosensitive

Cranioplasty Planning

If the patient survives and requires decompressive craniectomy, cranioplasty should be planned for approximately 3 months post-operatively. 4, 8

• This timing allows for resolution of cerebral edema and complete wound healing 8
• Inpatient admission for cranioplasty is appropriate given the complexity and residual subdural hematoma 8

Critical Pitfalls to Avoid

• Never delay neurosurgical intervention for bilateral hematomas of this size with uncal herniation—mortality approaches 100% without surgery 1, 9
• Never use hypotonic fluids or permissive hypotension in traumatic brain injury 1
• Never continue ceftriaxone beyond 7-10 days without clear indication, especially with neurological deterioration 5, 6
• Never assume traumatic etiology without adequate trauma history; bilateral temporal hemorrhages with soft tissue masses mandate malignancy workup
• Never forget to address the underlying malignancy—neurosurgical intervention addresses the immediate life threat, but systemic disease determines long-term prognosis

Prognosis

The presence of bilateral uncal herniation carries grave prognosis even with immediate surgical intervention 9. Contralateral vascular complications (Kernohan notch phenomenon, superior cerebellar artery infarction) may occur and worsen outcomes 9. However, if the underlying malignancy is chemosensitive (e.g., choriocarcinoma), aggressive management may still offer meaningful survival.