Right MCA territory Infarction with mass effect

Case: Refered from tanjung karang on 18/6/2009. 39 years old Indian gentleman, with no known medical illness developed sudden onset of left sided body wekness. He also had vomited few times whereby the vomitus was coffee ground.

Not on any medication. Been unwell since yesterday. Having nausea and persistent vomiting since yesterday. He was unable to tolerate much orally. Today had persistent vomiting too. At about 9 pm, had developed sudden onset of left UL and LL weakness associated with inability to speak. Denies having any headache, No giddiness, No fever, No preceding chest pain or palpitations. Married, Non smoker, occasional alcohol consumption

Examination:

Alert, Obeying commands. Expressive dysphasia. Gag reflex absent. Right UL and LL: dense hemiplegia with hyperreflexia.

Plantar upgoing right side

CVS s1s2 DRNM

lungs clear

PA-soft, non tender

Pupils - equal 3 mms, reactive.

Pulse 92 /min

Respiration 17 /min

Systolic Blood Pressure 117 mmHg Diastolic Blood Pressure 88 mmHg

SPO2 99 %
Analysis / Assessment
:
ECG - sinus rythm, LVH by voltage criteria

CT scan on 18/6/2009

Findings: Large ill defined wedge shaped hypodensity noted in the right fronto-parietal region with effacement of adjacent sulci. No midline shift. Ventricles and CSF-spaces are normal. Visualised paranasal sinuses are clear.

Impression: Right MCA territory recent infarct.

He underwent OGDS on 18/6/2009.

Findings:

Esophagitis LA grade B with gastric metaplasiaChronic atrophic gastritis with antral erosionsDuodenum normal

On the next day noted pupils were unequal. Patient opens eyes, obeys commands, localizing to pain but not verbalizing

Examination:
pupils unequal RT 4mm lt 2mm

BP 150/78

PR 74

Repeat Ct scan on 20/6/2009

Plain CT-brain on 20/6/09. Comparison with CT-scan on 18/6/09. Findings: The previously seen right MCA territory infarct become more well defined with increasing oedema. Associated mass effect to right lateral ventricle with midline shift 13 mm to left side. Hypodensity of midbrain, most likely represent ischaemia. Hyperintensity in basal cisterns and Sylvian fissures, suggestive of subarachnoid haemorrhage which was not seen before. Basal cisterns and sulci are effaced. Left basal ganglia recent infarct as seen before and not increasing in size. Left lateral ventricle is dilated.

He underwent right FTP decompressive cranictomy and left frontal EVD for ICP monitoring

Post-op he underwent cerebral resuscitation. Pupils 3s /2+. ICP maintanied below 20mmHg.

Post-op CT on 21/6/2009

PLAIN CT BRAIN: 21.6.2009 Finding: *** comparison with CT brain dated 20.6.2009. The left lateral ventricle is less dilated with EVD in situ. Lesser degree of midline shift to the leftc with shift of 4mm. Rest of the findings remains similar.