MALIGNANT MIDDLE CEREBRAL ARTERY INFARCT

65yrs/M Known CAD(RHD with MS) on Acitrom 1mg and Hypertensive(Olmesartan) was brought to the casualty with Complaints of Sudden onset of Right sided weakness and Aphasia,Right side facial drop 6 hour prior to the arrival.24hrs after admission GCS of the patient deteriorated immediately intubated and put on mechanical ventilation.Pupils B/l dilated fixed non reactive with Plantars B/l Mute.Neurology reference was taken, Explained poor prognosis. Chief Complaints Right sided weakness,Aphasia,Facial drop History CAD HTN Vitals Bp -160/90,HR - 120,Temp -102,Spo2 -98% with O2 support on 3L,RR -24 Physical Examination On presentation - Motor examination showed grade 0 power on Right upper and lower extremities,Pupils - Left 5mm SRTL,Right 4mm RTL,GCS - E1M3V1 Investigations WBC - 18000,D dimer - 5000, Coagulation profile - WNL,LFT and KFT normal Diagnosis DIAGNOSIS? Management Suggest Further management plan?

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Malignant left middle cerebral artery occlusion with cerebral infarction in the area of distribution. Also part of posterior cerebral artery seems to be involved with sudden deterioration in GCS to 4 . Prognosis is poor considering his neurological status. IV Recombinant t- TPA can be tried in such case when you have lost hope of survival Other options like solitaire endovascular stenting are not possible right now - but only if the,patient survives can be done

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Left MCA stem occlusion. Patient deteriorated after 24 hrs of admission. At present pupils dilated and fixed. What about the ocular movements,swallowing reflex.Pl check for brain stem signs.If brain stem signs are absent and the pt is deeply unconcious,one can diagnose brain death clinically. Brain death is a clinical diagnosis..Nothing can be done at this stage

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large infarct dominant hemisphere.. medical management only... a very deplorable practice of operating such patients is seen..decompressive craniectomy.... it's more for commercial gain rather than benefitting the patient and family.. surviving a vegetative life is not the goal of treatment

Intracerebral bleed. Neurosurgery opinion for decompression and starting of levetiracetam and mannitol

Left mca oclusion. Poor prognosis. Declare pt braindead if the brainstem reflexes are absent

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Decompression to be attempted.

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Massive Left MCA territory bleed with significant midline sifting to right side Poor prognosis Manage BP aiming to keep BP systolic 140-150mmofHg and diastolic 80-90mmofHg Give IV Levipil 500mg BD Inj. Mannitol 100ml TDS supportive management Advance cardio respiratory life support As early as possible take neuro surgeon opinion and plan for decompression surgery

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Stroke

Lt side cerebral haemorrhage

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Massive cerebral hemorrhage, lt. side with mid line shift Mannitol 20% tds. Meropenem 1 gm iv bd. Citicoline 500 iv bd General, nutritional management with iv fluids,and RT.feeds. Foley catheterization and monitoring of input output. Persistent evaluation of electrolyte. Optimal nursing Care , avoid bedsores.

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