Grand round discussion

DR. NYAONCHA A. N.

PC
Headache Blurred vision Nausea and vomiting

HPI
Known hypertensive patient since November 2011. Non compliant on treatment or follow up. Restarted on medication two weeks prior to admission as was not feeling well.

O/E

Patient in obvious pain, sick looking Rousable and able to communicate

BP 158/101, PR 66 bpm, SPO2 97% RA RR 18 bpm Pain score 10/10

CNS Conscious, rousable. Oriented in TPP GCS 15/15 Pupils 3mm BERL, Normal EOMM (later Lt pupil dilatation and ptosis) No cranial nerve palsies noted at initial exam Neck stiffness Normal cerebellar examination Normal motor and sensory examination

CVS

HR 80 bpm, S1 S2 reular, no added sounds.

Normal ECG. RESP P/A MSS

Impression Acute cerebral event R/o SAH Intracerebral bleed(EDH, SDH) Meningitis SOL

CT scan Subarachnoid hemorrhage, spill in the interpeduncular fossa, intraventricular spill (II IV). Fischer IV.
WFNS grade 2 Hunt and Hess grade 2

Plan Admit HDU Analgesics Sedation Evaluation: FHG, UE/Cr, coagulation screen. BP control CVP target 10 cm H2O Anticonvulsants

4 vessel study ..there is vasospasm of the left internal carotid Tjunction ..Lt anterior choroidal artery is spastic at origin. No obvious aneurysm or AVM demonstrated.

Repeat 4 vessel study (one week later) ..Lt posterior communicating artery aneurysmal dilatation at origin. Spasm at the left anterior and middle cerebral arteries.

Intra operative details Fronto-temporal-parietal flap Craniotomy and dural incision Dissection along sylvian fissure, gentle frontal lobe retraction Proximal and distal dissection Application of curved aneurysmal clip Washout and dural closure Replacement of bone flap and closure in layers.

Good post operative recovery.

Basic science theme

Anatomy of cerebral circulation (Internal carotid artery circulation) embryology and anatomy