DIAGNOSIS : Hypoxic ischemic encephalopathy MCA-PCA watershed zone infarct Systemic hypertension #neck of femur left, #shaft of femur left with multiple metatarsat #2, 3, 4, 5 HISTORY: 42 year old male, was admitted in West forte hospital Thrissur with history of RTA on 03/06/09.On 04/06/09 under went surgery under GA fort fracture of neck of left femur,shaft of left femur and multiple fractures in left foot (2,3,4,5).Post operatively patient was kept on ventilator for occasional oxygen desaturation. On 05/06/09 morning while preparing for extubation he had an episode of bradycardia and desaturation, hence vetilation continued. On 06/06/09 he developed an episode of AF, which was managed and patient was extubated. Initially patient obeyed commands but gradually his conditions worsened and became not able to respond verbally.CT Brain showed Traumatic SAH. He was continued on oxygen inhalation. Hence he had no significant improvement MRI Brain was done on 10/06/09, reported as normal. Hence came for further management. CLINICAL EXAMINATION: HR-84/MINUTE, BP-140/70 mmHg GCS: 6/15 PUPILS: PEARL Not moving limbs Extensor posturing to pain Upper limb reflexes-brisk B/L INVESTIGATIONS: Date: 12/06/2009 Potassiun; serun :3.68 mmol/L Sodium serum:145.5 mmol/L Date:11/06/2009 D-dimer;semiquantative-plasma :0.8 mg/L Triglycerides serum:166.05 mg/dl Cholesterol VLDL: 33.0mg/dl Cholesterol LDL serum: 118.3 mg/dl Cholesterol HDL serum: 30.8mg/dl Cholesterol total serum: 183.0 mg/dl Urine Fat globules: NEGATIVE PT [Prothrombin Time with INR]- Plasma: 15.5/14.60/1.07 s HIV – Emergency Screen: 0.05 Anti HCV –Emergency Screen: 0.02 0 HBs Ag Test- Emergacy Screen: 0.22 Urea – Serum: 60.2 mg/dl Creatinine;-Serum: 0.81 mg/dl Protein total serum: 6.2 g/dl MRI Brain: Edema and symmetrical altered signed intensities (bright on FLAIR,T2)seen in the precentral gyri which show restriction of diffusion in DW sequence. Altered signal intensities (parieto-occipital region) involving gray and white matter seen which are bright in FLAIR with diffusion restriction. Rest of the parts of cerebral hemispheres appear normal. Ventricles are normal in size. Sellar,suprasellar and parasellar regions appears normal. Brain stem and cerebellum appear normal .Evidence of a thin subacute bleed seen along the posterior aspect of the flax cerebri. No other intra/extraaxial bleed is seen. IMPRESSION: Symmetrical signal charges with diffusion restriction in precentral gyri and changes in the bilateral parieto-occipital regions(MCA-PCA watershed zone). Features of suggestive of Hypoxic ischemic changes. Thin subacute bleed along posterior falx. Dr. Does he get back his speech ?