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10-MARCH-2008 SHAWKAT MAHMOUD ISMAEEL 76 YEARS
RUPTURE GIANT ANEURYSM RIGHT M1 WITH MASSIVE ICH AND IVH.
Anamnesis:
The patient came to the
emergency of Shmaisani hospital the evening of
07-March-2008 with sudden loss of consciousness
and repetitive epiattacks. The patient was
immediately taken to the CT-scan, which
confirmed that there is a very massive
intracerebral hematoma right cerebral hemisphere
and both lateral and third and fourth ventricle
with interhemispheric extension with secondary
perforation to the right lateral ventricle.
The patient was gasping with
decerebrate rigidity, for what he was taken
urgently to the operating room.
A wide fronto-temporal
craniotomy was done and the heamatoma, which was
reaching the cortex at the precentral area was
attacked and removed. There was a very
huge aneurysm with wide base arising from the
right M1 was noted and the longest available
clip of Ausculap brand was used to occlude the
wide neck of the aneurysm, at the same time to
preserve the patency of the M1 segment. An ear
was noted at the distal part of the aneurysm
which was occluded with small clip. Inspection
of the wall of the aneurysm for running feeders
was negative.
The patient was kept in
ventilator with triple H therapy with small dose
of nimotop infusion, because he had exaggerated
hypotensive effect during the usual infusion.
Serial check CT-scan were
done at 12 hour interval, which confirmed the
persistence of the intraventricular hematoma.
The external drain was not functioning despite
its withdrawal for 20 mm.
The patient was taken to the
operating room 10-March-2008 and the flap was
reflected and the residual hematoma was removed
and inspection of the aneurysm was performed and
direct external drain was inserted to the
posterior horn of the right lateral ventricle
and meticulous irrigation was performed. A new
second external drain was inserted near the
aneurysm wall and was directed anteriorly to the
anterior edge of the wound.
Tracheostomy was performed
and the patient was sent back to the ICU with
the same medications.
Comments
The mortality rate in such
case is very high and aggressive measures must
be performed to increase the rate of survival.
The presence of the clot in
the lateral ventricles and the III and IV
ventricles will trigger the arterial spasm, for
what the second surgery was done.
The family for certain
reasons did not agree to put the patient in IOM
with ICU protocol. It will be nice if such
action was performed.
