60year old Man Collapsed at Farm at midnight brought at Hospital after 10 hours due to hidden Rural area.Presented with BP 130/80 mmhg,HR 96/min.RR:18/min.RBS:119mg/dl,RS: No Ronchi No Crepitation.Pt was not able to open his eyes and left upper limb absence of movement with left lower limb muscle power less then 3.Right upper and lower limb in active Form.Foly's in situ.Gag refex is preserved.pt Can speak with slurred.Advise to do MRI Brain.Angio not performed due to unaffordability.Kindly suggest Proper diagnosis and Management.at local rural hospital..

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Large right sided MCA infarct Management - Inj Mannitol 100 ml TDS, Tab Amlod 5 mg OD, High flow Oxygen, IV fluids, ECHO, Carotid doppler Aspirin hold to prevent reperfusion bleed.

Blood pressure below 150mmhg..but now it's above 170mmhg. So we can use Manitol now.
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Acute infarction Rt MCA with mild edema as noted by compression of rt lateral ventricle with out midline shift No noticable risk factors. Check for lipid profile,uric acid,cardiac evaluation. Start antiplatelet,DVT prophylaxis,neuroprotective if available,good hydration , check for worsening of neurological status,rept CT brain 24 hrs ,earlier if deterioration,rehabilitation care. Expecting good prognosis at this stage.

large Rt.mca malignant infarction without mass effect mostly parietal with HEMORRHAGIC transformation,reperfusion injury. look for mechanism of stroke artery to artery / cardiac Medical treatment - aspirin - statin - hydration with normal - saline watch for neurological deterioration of worsen may think decompression.

Sir....As per my experience and opinion u should directly go for elective decompression as it is .massive hemispheric infarct edema 'll definitely increase even high dose of mannitol so don't take risk....

Sir what are the outcomes after elective decompression.
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Right large MCA Infarct Inj Mannitol Inj Epsolin Inj leveracetam Antiplatelets bt use cautiously O2 supplementation W/f GCS..pupils SOS Intubation n ventilation Decompressive craniotomy suggested

Right MCA territory infarct.

Extensive Rt M C A infarct .In a rural set up it's difficult to manage . Decompressive craniotomy may be necessary as well as IC U management.Othervise only conservative management.

Sir its obvious infarct....but sir is it good aprroch to do ct scan brain first as it has low cost compare to mri....and obviously early infarct not detected in ct but classical features of hemiplegia and no bleeding in ct then most likely infarct....and we can repeat ct after 24 hr.....its opinion sir....as mri is still costly for india people

Absolutely correct sir but in rural place first no body gives you correct history they day by day gives you different information.Some tells just happened, some tells other things..so better to do MRI so we can not miss any thing.Thnak you for finding this thing.
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Since it's a large MCA infarct, and presented at out of window period, thrombolysis option was ruled out. He has to b managed with antiplatelets, stains, along with other neuroprotective measures and continoues neuromonitoring...

Acute right MCA territory infarct

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