A 48yrs old male presented to ED having H/o sudden onset LOC and seizure with multiple episode of vomitting.K/c/o HTN not on regular treatment as advice by his family doctor.O/e CNS - conscious,alert,oriented,Right UMN facial palsy,Both pupils are normal in size.GCS-E3V4M4,Bp-170/90mmhg.Diagnosis?



A large left intracerebral haemorrhage due to uncontrolled hypertension with ventricular extension,midline shift and cerebral oedema . Start mannitol 8 hourly, inj Eptoin 8 hourly, urgent control oh hypertension, decompression of clot,evacuation of clot , placement of EVD . Post operative ventilatory support and supportive care with correction of fluid and electrolyte replacement including blood transfusion if required

Why blood transfusion

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Please clarify about neurological status 1. Concious , alert, oriented which is GCS 15/15- then medical management OR 2. E3V4M4 that is 11/15- then ventilation SOS surgery Please follow protocol of medical management http://banuprakashas.blogspot.in/2013/06/neurosurgery.html?m=1 Sms me your email I'd for complete new edition of protocol management Neurosciences Ideas comes like lightening, eureka, its not my way to greedily hang onto it be it medicine, life, politics to selfishly implement it myself, waiting for top person or stage to gain money or fame.   Thats the reason of my blog. Its got pearls of my understanding of life. For after I lost two extremely intelligent friends one for infection, one in accident both perils of mismanaged society.  My endeavor in AAP togive those two souls peace n assurance that not many get lost in future. Thats my shraddhanjali to them for which I would work till last breath. Few of the other posts are strong worded to give truth its due for You know im not afraid of death ensuring i live my bucket list as and when possible, but just wantu inspire as many before  TO LIVE AS THOUGH YOU WILL DIE TOMORROW  &  LEARN AS IF YOU LIVE FOREVER preventive neurosurgery  helmet, NO drink n drive, mobile phone handsfree cords avoid jerks n bumpy rides for spine health early consultation n MRI to prevent secondarily complications of diseases preventive strategy for the family members for primary prevention HEADACHE management stop smoking and alcohol, Take plenty of water, raw-vegetables,sprouts,fruits,overnight soaked nuts, butter milk,honey-ORGANIC, sunlight exposure, pranayama & ASHTANGA yoga, Music tl  http://banuprakashas.blogspot.in/2013/09/health.html target="_blank">http://banuprakashas.blogspot.in/2013/09/health.html target="_blank">http://banuprakashas.blogspot.in/2013/09/health.html target="_blank">http://banuprakashas.blogspot.in/2013/09/health.html BP , Physician opinion to rule out hypertension Tab ECOSPIRIN 75 mg 0-0-1 or 1-0-1 or 1-1-1 according to weight n severity Tab crocin 500 when pain Psychiatry opinion if stress/ depression Rule out cervical/ CVJ- RA related occipital neuralgia If migraine with nausea.... T.Naxdom SOS 250mg 1-0-1 if weight<50 kgs, 500mg 1-0-1 if wt>50 kgs. when severe headache with lack of sleep patient is lean T.Tryptomer or T. profigran 10mg  0-0-1 patient is obese, T.Topema 25 mg 0-0-1 or 0-0-2 acc. to body weight If temporal arterial tenderness tab microcid. 75mg 0-1-0 or tab wysolone 10mg 1-0-0 NEUROLOGICAL EMERGENCY-UNCONCIOUS PATIENT Asses GCS, pupils,  vitals, Spine Immobilisation (trauma, hanging)-spine board, head block with strap A B C D E F G H I of emergency care. physician, surgeon opinion Correct hypoglycemia, hypoxia, hypovolemia, hypercarbia, electrolyte abnormality and correct. under alcohol influence.....Check GRBS <70 dextrose 25%, inj thiamine 100mg IM if hypotension<90 mm HG take blood sample for serum Na, Hypertonic saline bolus according to GCS 100 for 14-12 , 150 for 11-13, 200 for 10-7, 250 for 8-7, 300ml for 6-3 If SBP >90 Mannitol in ml per Kg body weight STAT dose, frequency as per GCS at time of giving the dose 1.5  for 14-12 , 2  for 11-13, 5 for 7-10, 6 for 4-6, 8 for 3.  If unconcious inj Valparin 20 mg/kg stat, 10mg/kg BD reassess GCS after CT scan and repeat if severe edema and no improvement . consider for EVD, surgical procedure if needed Low GCS <10, Pupillary asymmetry, severe brain edema / MLS-midline shift : intubate and ventilate. HEAD INJURY MANAGEMENT Inj eptoin 20 mg/kg in 100 ml NS over 20 min followed by 5 mg/kg/day. Inj pcm 15 mg/kg bd Iv emeset 1mg tid Iv pan 10 mg BD IVF NS+mvi @ 1ml/kg/hr adjusted according to I/O, fever, CVP Get PT, INR , group cross match, Baseline Serum electrolytes...Na under alcohol influence.....Check GRBS <70 dextrose 25%, inj thiamine 100mg IM If GCS<15 Inj mannitol 1.5ml/kg tid 3%saline 100 ml+1gm MgSO4 @ 0.5ml/kg/hr if sodium <120, 0.4<125, 0.3<130 ,0.25<135, 0.2<140, 0.15<145 monitorserum Na BD/OD. Tab minocycline 200 mg  1-0-1 If not allergic to sulfa drugs SC inj/Tab glybenclamide check GRBS General surgery opinion to rule out polytrauma, Faciomaxillary opinion SOS Abrasions H2O2, betadine, T bact oint. Laceration-debride suture under LA, IV antibiotic Music therapy , stop smoking and alcohol, pranayama & ASHTANGA yoga, physical labour, meditation and forgiveness, adeqaute water, raw-vegetables, sprouts, fruits, overnight soaked nuts, butter milk, honey-ORGANIC, sunlight exposure. http://banuprakashas.blogspot.in/2013/09/health.html HEAD & SPINE INJURY MANAGEMENT  https://docs.google.com/file/d/1j7t-CyslNvJTNJPaTG_q,qO4kcFKq_i6Jvr4-0f3-L5CJUp13t7mJkcjpq9wM/edit?usp=sharing STROKE MANAGEMENT Emperical therapy Tab atorvastatin 40mg stat, HS Tab citicholine 500mg BD Tab nootropil 800mg TID Cap Minocyclin 200 BD Inj mannitol 1.5ml/kg tid if unconcious , edema Inj pcm 15mg/kg bd if headache Iv emeset 1mg tid if nausea Iv pan 10mg BD if unconcious IVF NS+MVI@ 1ml/kg/hr adjusted according to I/O, fever, CVP Get PT, INR , group cross match Serum electrolytes...Na 3%saline 100ml+1gm MgSO4 @ 0.5ml/kg/hr if sodium <120, 0.4<125, 0.3<130 ,0.25<135, 0.2<140, 0.15<145 Inj eptoin 20mg/kg in 100ml NS over 20min followed by 5mg/kg/day if cortical bleed/LOC Inj dexa 0.04mg/kg BD if severe edema, deep coma, hypothalamic/adrenal failure ISCHEMIC A) if no bleed on CT  , patient had come within 4 hours of anterior circulation stroke n 12hrs of posterior circulation stroke onset.. IV thrombolysis with Alteplace or rTPA based on NIHSS score n inclusion criteria. If no improvement or beyond then attempt of intraarterial thrombolysis or recanalisation till 8 hrs in anterior  48 hrs in posterior circulation strokes https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4564430/ B) If beyond thromolysis period   Inj heparin 2500 units BD HEMORRHAGIC  C) If bleed keep BP <140/90. amlodepine, ACE inhibitors, labetelol, SNP Inj eptoin 20mg/kg in 100ml NS over 20min followed by 5mg/kg/day if cortical bleed/LOC If affordable Inj edaravone 30mg BD Inj cognipro 60mg OD Inj LMWH 40 units or heparin 2500 units HS for DVT prophylaxis,TED stocking, sequential compression device. vasculitis profile, lipid profile, group cross match, ECG, ECHO, carotid-vertebral doppler. Physician opinion for hypertension, diabetes, vasculitis,nephropathy, retinopathy, cardiac/mesenteric ischemia Physiotherapy Music therapy , stop smoking and alcohol, pranayama & ASHTANGA yoga, physical labour, meditation and forgiveness., adeqaute water, raw-vegetables, sprouts, fruits, overnight soaked nuts, butter milk, honey-ORGANIC, sunlight exposure   http://banuprakashas.blogspot.in/2013/09/health.html . SPONDYLOSIS cervical/dorsal/Lumbar---Brace accordingly Physiotherapy Avoid potatos, oily foods, fried foods, tomatos stop smoking and alcohol, pranayama & ASHTANGA yoga, physical labour, meditation and forgiveness., adeqaute water, raw-vegetables, sprouts, fruits, overnight soaked nuts, butter milk, honey-ORGANIC, sunlight exposure   http://banuprakashas.blogspot.in/2013/09/health.html Tab ECOSPIRIN 75 mg 0-0-1 or 1-0-1 or 1-1-1 according to severity Tab crocin 500 1-1-1 when pain Tab ultracet 1-0-1 Tab Nervigen (B1,B6,B12)  1-0-1x 0 days Tab. Riconia Silver (vitamin minerals)  1-0-1 x 10 days Tab Calcimax K2(Ca,Mg,D3) 1-0-1 x 10 days Tab Amitryptalline 10mg 1-0-0 x 10 days if severe pain or associated with depression symptoms vitamin D sachet 1/week If postmenopausal  cap.primerose oil 1-0-1*10days Tab Neurikem-M(pregablin) 75 1-0-1 x too severe pain Music therapy physicion opinion to r/o polyarthritis if no improvement MRI If osteoporosis Tab ostiofos (alendronate) 70mg 1 tab per week in empty stomach in sitting position with plenty of water, breakfast after 30 min.....avoid in asthmatics EVD  EVD is an emergency life saving procedure to be learnt by all emergency physicians like a chest tube, endotracheal tube, central line-venous cut down http://en.wikipedia.org/wiki/External_ventricular_drain the trajectory is to be perpendicular to the skull/brain surface where ever you are...Dr Ashish Pathak, PGIMER as the condition worsens with increasing edema the ventricles get chinked and shifted more medially towards the midline than from the last CT image a life saving procedure when done at the correct moment for many a situations arent stable enough for surgery and not getting better with medicines alone a factory had a celebration on year end 31.12.2009 with sweets n food distributed. few felt a little sick the evening  but postponed till next day when many started complaining of stomach pain, vomiting totalling to 440 patients lying all over the floor n corridors of hospital one 30yr lady mother of 2 children with vomiting n dehydration brought o hospital on a bike sitting between the driver n pillion men, walked with support to casualty, became drowsy and non responsive so after IVF,antibiotics, antiemetics,pantoprazole she was shifted to CT which showed diffuse cerebral edema suggesting metabolic encephalopathy. mannitol, dexa given but she continued to worsen with dropping blood pressure 90 and GCS M3, little while later pupil right 3 and left 2mm. now BP 70, GCS M2 with ECG showing Ventricular tachycardia with ectopics no improvement with colloids n crystalloids intubation. a relook at the CT showed slight enlargement of rt frontal horn as compared to the left so with hot debate of pros n cons a rt frontal EVD inserted which rapidly stabilised her condition n she was concious next day MRI showed borderzone minimal infarcts n she walked back home to her children after 5-6 days ACM syrinx OBEXOSTOMY  ACM is usually treated with FMD -Only bony decompression- if only there are symptoms of posterior fossa inadequacy like cough headache with bony compression in children + Dura – adults where the dura in inelastic, after bony decompression children if there appears a constriction band without a smooth funnel of posterior fossa into the spinal dura. Where in the small herniated tonsil can ascend back + arachnoid if the herniated tonsils are atrophic and elongated may be an arachnoid constriction can be there, adults where there appears a band after dural decompression and the tonsils doesn’t ascend up and posterior column of CSF  not established +tonsil shrinkage /resection too long tonsils doesn’t ascend and tightly adhered in the midline obscuring the obex preventing CSF outflow from the megendie and obex to cut the arachnoid bands to ensure same +syrinx decompression if the patient has tense syrinx on MRI alone or moderate syrinx with syringomyelic syndrome then previously we had done separate incision at maximum dilatation or superficial pointing of syrinx. We did syringostomy or syringosubarachnoid shunt usually at cervical or dorsal region with mixed results of improvement, funicular pain, new weakness especially with shunt tube. Nowobexostomy can be an option if it extends till obex. 24yr student presented with paraesthesias of both hands and fingers with wasting and weakness of left hand muscles. He had dissociated sensory loss for temperature and pain in the left upper limb. MRI showed a shallow posterior fossa with tonsillar descent and cervico thoracic syrinx. Since his major symptoms were due to the syrinx we planned for a FMD and syringostomy or syringe subarachnoid shunt. Introp after opening the dura and arachnoid, the tonsils were shrunk by coagulation and megendie opened to release 4th ventricle CSF. In the obex there was a thin membrane of arachnoid/pia which I cut with scissor and probed the obex gently with ball point probe inferiorly, slow trickle of CSF like fluid came out which increased with each probing. The cord seemed decompressed so separate syringostomy was not done.post op patient had complete recovery of upper limb symptoms confirmed by post op 10th day MRI showing syrinx decompression. My first case of obexoplasty was ACM with cervico dorsal syrinx with dorsal scoliosis. There was a gush of fluid after opening the obex, I had to be sure that it was from syrinx and not the assistants irrigation or surrounding CSF. So went ahead for c5 laminectomy and durotomy to find the cord totally collapsed. Subsequent cases with syrinx have achieved good improvement but had not imaged any of them. One case of chiari 3 child with syrinx had imperforate rhombic roof with obex patent   dynamic stabilisation-MOTION PRESERVATION of spine-a biomechanical possibility With routine protocol dislocation or instability is treated with rigid fixation ensuring stability at the cost of mobility. Instability in spine is like any joint due to ligamento-muscular laxity. The orthopedicians rarely fuse appendicular joints now-a-days  By understanding the forces causing instability or the factors preventing its occurrence in normalcy instability can be a correctable pathology with negating the prime vector of cause or strengthening the vector to prevent it. Various methods of fusion have been done in past with improving biomechanics over the years.  Using the techniques of exposure practiced for minimally invasive or functional preservation the vitality of the vectors are maintained or strengthened to stabilize the spine. If the dynamics and vectors are preserved there is no need for arthrodesis hence mobility is preserved as exemplified in all levels of instability from CVJ to LS spine.  Drain removal in Lumbar fusion n Infection rate   http://www.linkedin.com/groupItem?view=&gid=1725597&type=member&item=205157390&commentID=144674568&goback=%2Egde_1725597_member_250298549%2Egfl_1725597&report%2Esuccess=8ULbKyXO6NDvmoK7o030UNOYGZKrvdhBhypZ_w8EpQrrQI-BBjkmxwkEOwBjLE28YyDIxcyEO7_TA_giuRN#commentID_144674568 infection in lumbar fusion depends on the immune status of the  patient, microvasculature-DM, length of surgery, loss of vitality of tissue with excessive retraction/cautery, washes, antibiotic choice- susceptibility pattern, n the duration of drain depends on the ozziness of the tissue- water logged, dependent edema, myxedema, fat necrosis, hemostasis-coagulation ability, clot retraction pattern, lymphatics n venous drainage of area..............definitely a sterile clot as in trauma gets absorbed but a clot or collection seeded with organism in low immunity is culture media........many a times blocked drains show pseudo decrease in the bag n when you pull  out the dressing keeps getting soiled with discharge........its not a simple arithmetic of numbers its an instinct refined by subconscious logic based on observation of all the current facts n analysis in comparison with of the previous success n failures. SEVAKSHETRA HOSPITAL, SITA BHATEJA Hospitals charitable  OASIS in the capitalistic MEDICAL DESSERT. one day we performed a pooja at home, at the end when he was asked how much to pay, he a TRUE BRAHMIN said my travelling charges are 600 and anything above it would be gracefully accepted. likewise we are offering neurosurgical care like a TRUE BRAHMIN as an act of meditation and enlightenment SARASWATHI....THE GODDESS OF KNOWLEDGE....LET US REVIVE THE RIVER the concept of let go of the beautiful work one does after its done helps to explore new paradigms of knowledge by greatest thinkers in history..... the act of expecting the benefits of efforts makes one lazy to relax n bask in the attention rather than explore new dimensions....that is what Dr Fessler n Dr Sekhar are doing.....i believe till the concept of copyright n patents r there actual science will be market controlled.........science will become equal to GOD n NATURE the day it flows like a river free for all.. https://www.facebook.com/groups/neurosurgerydoctors/ Forum Of Neurosurgery - منتدى جراحة المخ و الأعصاب Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves http://ublog.dd.rapidbaz.com/1ST/H565.A.o.N.T.S.a.P.N-ublog.t.k.part1.rarhttp://ublog.dd.rapidbaz.com/1Sm/H565.A.o.N.T.S.a.P.N-ublog.t.k.part2.rarhttp://ublog.dd.rapidbaz.com/1SF/H565.A.o.N.T.S.a.P.N-ublog.t.k.part3.rar http://neurosurgery.ucla.edu/body.cfm?id=1075 https://mega.co.nz/#!e9xhlAAb!dcrwsjxYs24605X7T3UaxFrWqxEgRekzP5DUjznhrl0 https://mega.co.nz/#!nAETFKDR!NdV9JWkAfUktChh1jEjNvByOUdsCoL8Zaaz2h9jhdx8 Password is : greenberg John Peter Paiso

Left temporoparietal parenchymal bleed with midline shift. gcs monitoring vital monitoring iv acess dilantanization electrolytes and temperature monitoring in raised icp situation head elevation mannitol

Left thelamocapsuloganglionic bleed with involvement of adjacent white matter of temporal lobe ,blood in the 3rd lateral and 4th ventricle with brain edema and midline shift.Most probably hypertensive bleed

Intracranial haemorrhage with intraventricular extension and midline shift. Neurosurgical consultation

Ich with ventricular extension &midline shift.reduce icp .antiepileptics.&brain can be decompressd&the clot can be evacuated.evd can be placed for ventrcle bleed.you didnt mention hemiparesis.

Hypertensive capsular bleed Try and manage conservatively

Left intracerebral Hypertensive bleed with midline shift Control BP Start AED mannitol NEUROSURGEON opinion

IC hemorrhage, control BP.Mannitol iv,Monitor, Don't use aspirin and clopidogrel .


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