Carotid endarterectomy

Arnold Chiari Malformation

Left FP ASDH

Referred case from ED yellow zone

16yo malay boy
No known medical illness

Alleged MVA this morning
MB vs MB, at 7.15am near Sek Men Teknik Paya Jaras today Had LOC ? duration, regained consciousness on the way to hospital. No vomiting
No limb weakness- able to move all limbs, but noted by ED MO pt a bit restless- given sedation prior to CT brain done
No ENT bleeding
No SOB/ chest pain/ abdominal pain

o/e:
GCS E3V3-4M5 (11-12/15)
Pupils 3/3 ++
Noted multiple abrasions wound (small) over the face

Chest/ pelvic spring -ve

No spine tenderness
No obvious long bone deformity

BP 135/87
HR 90
Spo2 100% on air

Lungs: clear
P/a: soft, nontender

Moving all 4 limbs power bilateral UL/LL >4/5
Reflexes normal

CT brainLt frontal contusion with Lt frontoparietal SDH with maximum thickness 0.5cm over 10cuts MLS 0.5cm Brain edematous BS partially efface

Impression: Lt frontoparietal SDH with Lt frontal contusion

He unerwent craniectomy and evacuation of clots with EVD placement for ICP monitoring. Post-op CT scan was performed POD 1

Left FTP CSDH

REFERRED CASE FROM ED RESUS

33yo chinese man
Background problem:
1) Young HPT (diagnosed 6 years ago age 27-28 years old), last seen by medical team in July 2009 Carotid doppler done: Left ventricular dysfunction, left ventricular thrombus, left internal carotid artery occlusion- on warfarin


2) CVA with dense right side hemiplegia and global aphasia (admitted in medical in Oct 2008- had neurorehabilitation)



Patient was admitted there from 22nd October 2008 to 1st May 2009 :

Hx from brother:
Presentd with less responsive, noted by family members since 2days ago. Condition worsened as previously pt was ADL independent, eventhouigh had Rt sided hemiplegia + global aphasia- pt was still able to bath/ eating by himself. This morning noted that pt was drowsy + PU in bed
. Hence, the family members brought pt immediatly to ED. Family claimed no h/o trauma at home. Compliance to medications - but last night ? took medications (including warfarin) by himself- no eye witness on how much he took
No fitting seen
No vomiting
No SOB/chest pain
No abdominal pain
No other complaint

o/e:
Opening eyes spontaneously, on + off obeying commands
GCS E4V1(global aphasia)M5-6
Pupils 3/5 sluggish

BP 160/82
HR 100
Afebrile
Spo2 99% on air

Lungs: clear
P/a: soft, nontender

Tone: Rt UL/ LL increased, Lt normal
Noted Rt sided body hemiplegic- 0/5, Lt UL/LL >3/5
Reflexes left sided briskBabinski: bilaterally downgoing

CT brain: Lt pareital acute SDH, maximum thickness 1.3cm x 4.4cm (AP), over 10cuts MLS of 1.6cm to the right, sulci & gyri not well differentiated- ? generalize edema Lt lateral ventricles compressed- pushed to the Rt, rt temporl horn opened BC partially efface Blood ix: FBC: WCC 8.4, Hb 14.3, Plt 243 RP: U 8.8/ Na 139/ K 3.7/ Cr 86 PT/APTT: 10.8/22.2 INR: 1.15 Impression: Lt parietal acute SDH ? 2' to overwarfarinization

He underwent craniectomy and evacuation of clots. Intra-op FFP was transfused. Post-op he was ventilated and sedated.Sedated on IV midamorphine 5mls/hr o/e:Pupils 2/3 sluggish BP 122/88HR 102AfebrileSpo2 99% on air Noted still slowly oozing head drain site Head drain 22cc

Repeated CT brain post op noted:Reaccumulation of bleeding.
He was subjected for another operation
Post-op, he was put on sedation and ventilation support. A repeat CT scan was performed.