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.

Traumatic Chronic Subdural Hematoma

Case: 67 years old Chinese gentleman, referred from HTAR on 27/6/09 with history of alleged fall at home 2 weeks and became disorientated and bed-ridden 3 days prior to admission.

He was admitted previously on 23/5/2009 when he was alleged fell at home on the same day with admission GCS of E4V2M5. CT scan done showed right frontal ICH. He underwent craniotomy and evacuation of clots and discharged home with full GCS.

On arrival his GCS was E3 V2 M5 with pupils 3+/3+.
BP 146/76,

HR 76

Afebrile

Spo2 100% on air

Lungs: clear

CVS: DRNM

P/a: soft, nontender

Able to move all 4 limbs but unable to assess proper power

CT brain

Mixed hyp & hyperdense lesion - SDH in left frontoparietal

Thickness 4cm

Local mass efeect on ipsolateral ventricle & contralateral MLS

BC still patent

Evidence of previous Rt frontoparietal craniectomy + encaphalomalacia Rt frontal lobe

Impression: chronic Lt frontoparietal SDH

He underwent left parietal burrhole and drainage on 27/6/09. Post-op he is remained ventilated and sedated.


Post-op CT scan on 28/6/09



NON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.

Written Clinical Comments: post Burrhole drainage

Findings:
***No previous image in the PACS for comparison.

Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.

Impression:
ICB with midline shift.

He underwent left parietal mini-craniotomy and subdural drainage on 29/6/2009





NON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.

Written Clinical Comments: post Burrhole drainage

Findings:
***No previous image in the PACS for comparison.

Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.

Impression:
ICB with midline shift.

On POD2, he was extubated. Pre-extubation GCS E4 VT M6.