Basilar artery thrombosis clinical meet

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My case presentation on Basilar artery thrombosis

Text of Basilar artery thrombosis clinical meet

  • 1. CLINICAL MEET CASE OF ALTEREDSENSORIUM 6/12/2013Dr.Ram Raut (JR III)

2. Case History 16 yr male student R/O- Beed. Admitted in private Hospital on 11/11/2013. With H/O1) Headache 3 days back more in occipital area , continuous & moderate intensity. associated with neck pain 2)Sudden onset unconsciousness since 1 day.No H/O Vomiting, visual complaints Head injury, Convulsions Chest pain, palpitations, breathlessness Fever, Cough with expectoration. Abdominal pain Substance/drug abuse 3. Past History H/o Few Seizures in childhood but not on any Rx. Not a k/c/o- TB/DM/HTN/CVA/BA/CHD. No H/O- similar episode in past. Family History No significant illness in family. No H/O Consangious marriage. No H/O sudden deaths in family. Personal History No addictions. 4. General examination Afebrile P- 100/min regular. BP- 130/80mm Hg Pallor + No icterus /edema /clubbing /cyanosis No Lymphadenopathy. JVP- Not raised. No e/o neuro-cutaneous markers. 5. CNS Examination Unconscious, Not responding to DPS GCS- 3/10 Pupils- B/L CCERL Dolls Eye- present Spontaneous Respiration present. No meningeal signs No Cranial Nerve deficit.Motor examination Nutrition- N Tone - Increased on right side DTR BJ TJ++++SJ++++KJ+++ ++AJ Plantars -+++ +++++ ++ 6. Other Systems CVS S1S2 Normal No murmurs RS AEBE clear No rales/ rhonchi P/A Soft, Non tender No organomegaly 7. Provisional Impression ? CVA ? IC Bleed Treatment started .. IV Mannitol IV antibiotics And IV fluids. MRI Brain (P+C) 1) Acute infarct in the right lobe of cerebellum; Restricted diffusion on DWI. 2) Small old gliotic areas in both lobes of cerebellum 3) Lacunar ischemic areas in midbrain.Aspirin, Atocor started & patient was referred to SGH for further management. 8. In SGH Patient got admitted in MICU. O/E Afebrile P- 96/min regular, all peripheral pulses well felt BP -130/80 mm Hg RR- 16/min CNS Examination No P/O/L/I/C/C Comatose Motor examinationJVP- NR CVSS1S2 Normal RSAEBE clear P/ASoft, NT L0S0K0 Min responding to DPS GCS- 5/10 Pupils- B/L CCERL Dolls Eye- present Spontaneous Respiration present. No meningeal signs No Cranial Nerve deficit. Fundus- B/L WNL Nutrition- N Tone - Increased on right side DTR BJ++TJ++++SJ++++KJ ++++++++AJ+++++ Plantars - 9. Investigations Investigation12/11Hb14/1120/11Investigation14/1120/1115.6SGOT1615TLC11.6SGPT4143PLC234ALP134164HCT54Bilirubin0.60.7MCV91Total proteins7.27Creat11.20.9Albumin4.54.3Urea655654Globulin2.72.7Na132134137PT2125K4.54.34.2LDH260BSL124ESR54Malaria AgNeg.PBS- Normocytic, few microcytes, mild hypochromia, TLC- 10,000. N72, L26 Platelets adequate.Uric AcidUrine analysis - WNL8.2 10. CXR & ECG - WNL 11. D2 Patient improved to some extent. Neurosurgery reference Continue conservative management. 2 D Echo No RWMA Good LV contractility. Intact IAS & IVS. MRI Brain & Angiography done 12. Acute infarct in Right inferomedial cerebellum T2/FLAIR Hyper intense. Acute infarct in pons T2/ FLAIR hyper intense 13. Right inferomedial cerebellum Restricted diffusion on DWI.Left pontine infract Restricted diffusion on DWI. 14. MR ANGIO 15. Acute infarct in right cerebellum, & left pons & midbrain. Gliosis in left cerebellar hemisphere. Thrombotic occlusion of left vertebral & basilar artery & right posterior cerebral artery. Blood samples withdrawn for thrombotic work up including Serum Homocystine, APLA, ANA p-ANCA, c-ANCA. Sample was also preserved for further workup if requires. & LMWH started. 16. D3 Now Patient improved neurologically. Regained consciousness. On Neurological examination Conscious & obeying. No neck stiffness No cranial nerve deficit. Right hemi-paresis present. Plantars- right extensor & left flexor Patient was shifted for DSA. 17. DSA 13/11/2013 Anterior circulation - normal caliber & blood flow. Total occlusion of mid basilar artery immediately distal to the AICA origin. B/L PCAs & distal basilar artery fill via B/L Posterior communicans. 18. Further investigations LIPID PROFILERESULTDESIRABLE VALUETOTAL CHOLESTEROL11460TGs74