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Case Discussion

Cerebrovascular Disease!!!!!!!   Posted By Nishant Chadha    Date : 19-Feb-03   01:19 PM     Reply

Hello ! Sir, 19-2-03 I am a medical graduate from Delhi,India and wish to enhance my knowledge in regard to certain medical problem . Here I am presenting you with not so uncommon medical problem – Cerebrovascular Disease . This is the case history of my close relative who battles to survive in a reputed private hospital in Delhi. The patient 60yrs. Old male known case of CAD( Coronary Artery Disease ) / Diabetes Mellitus was expected to undergo bypass surgery towards the end of this month until 4days from now when he had acute attack of cerebral ischemia leaving him with Left sided Hemiperesis . NCCT head showed :- Subtle hypodensity in Right Superior Frontal Region with partial obliteration of adjacent sulci,which may present as early infarct . IMPRESSION :- Possible early infarct in Right MCA territory. MRI brain advised for further confirmation. His ECG showed changes from V2 to V6 . At the time of admission his BP was 160/90 . The patient according to family initially showed some signs of improvement but 2 days ago did not respond to their calls .He lay unconscious and he was shifted to ICU .At that time BP was 210/110 and MRI was done. MRI report :--- # A large altered signal intensity area ( hypointense on T1W and hyperintense on T2W,FLAIR,diffusion weighted images s/o Acute Infarct)seen in Rt.Frontotemporoparietal region. # Rt.Thalamoganglionic region shows blood as evidenced by hyperintense signal on T1W,T2W,FLAIR images. Minimal extension of blood in Lateral Ventricles as evidenced by fluid level in Occipital horns. # Combination of above described findings of infarct and hemorrhage resulting in ----- a) Compression,effacement of Rt.Lateral Ventricle. b) Effacement of 3rd ventricle. c) Subfalcine herniation to left(approx.18mm) d) Rotation of midbrain with flattening/compression of lt.cerebral peduncle. e) Hyperintense foci in midbrain on T2W images (??due to squashing of Cerebral Peduncle along Edge of Tentorial Incisura) f) Rt.Medial temporal lobe herniation over Tentorial Incisura. g) Effacement of Suprasellar Cistern h) Dilatation of Lt.Lateral Ventricle

IMPRESSION:- In correlation with given clinical history,MRI features s/o :- # Acute infarct Rt.MCA territory. # Hemorrhage Rt.Thalamoganglionic region (MCA territory with intraventricular extension causing Subfalcine herniation and descending Transtentorial herniation )

So,these are the CT & MRI reports . During his stay he has been given Clopidogrel & LMW Heparin . Due to CAD ,he had been taking Disprin (Aspirin) . His sugar is on higher side .BP fluctuates . At present he has been put on Ventilator .He has been having few respiratory efforts. The patient is nonsmoker/nondrinker and recently married his only son . His daughter married for 5yrs.

Doctors there expressed a little hope of his recovery .I can understand that being in same profession. Sir,Is there anything else we could give a try to besides waiting by the side of ventilator ? Is there anything in Medical Science that offers some ray of hope ? One question has been going thru my mind .As in case of head trauma patients ,decompression procedures are used to prevent blood etc. from applying undue pressure on brain , can this be done in this case also ? Does any procedure which aims to remove extra pressure on brain benefit the patient at this stage ?

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