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10-MARCH-2008  SHAWKAT MAHMOUD ISMAEEL  76 YEARS  RUPTURE GIANT ANEURYSM RIGHT M1 WITH MASSIVE ICH AND IVH.

Anamnesis:

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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.

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The patient was gasping with decerebrate rigidity, for what he was taken urgently to the operating room.

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A wide fronto-temporal craniotomy was done and the hematoma, 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.

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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.

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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.

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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.

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Tracheostomy was performed and the patient was sent back to the ICU with the same medications.

Comments

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The mortality rate in such case is very high and aggressive measures must be performed to increase the rate of survival.

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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.

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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.

 

 


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