The patient was transferred from Islamic hospital after staying there for 3 days. He was admitted there walking and talking and CT-scan of the brain done 30-May-2017 showed huge bilateral convexital subacute subdural hematoma more the left side. The patient underwent stinting 6 months ago and was in Plavix. The Plavix was stopped and as the family reporting he was gradually deteriorating, for what he was transferred to our department. 

On examination, the patient has atrial fibrillation with cardiomegaly and he was in obtundation, with great effort to pronounce his name with quadriplegia. He has vomiting attacks and the relatives telling that at the morning he was able to move his left hand. The patient was urgently sent for another CT-scan of the brain, confirming enlargement of the hematomas. The relatives insisted to be seen only by his cardiologist. His cardiologist sent his assistant and reported that the cardiac functions are in bad condition and the risk of death even without surgery is very high. The time was 6.30 p.m. and it was agreed to be under strict observation by his cardiologist after surgery.

At 10.00 p.m. 2 bur holes were created in each side with the anterior ones locating at the frontal area and the posterior ones in the postero-parietal location. evacuation of the hematomas was stated until a clear fluid start to come out with saline. It was noticed that the both hematomas were communicating with each other during irrigation. External drains were inserted for each side.

Smooth postoperative recovery. The patient level of consciousness improved and the left side regained full power, but still having right sided plegia. The patient was sent to the ICU at 1.00 a.m. the morning of 03-June-2017 for observation.

The patient one hour later progressed myocardial infarction and Chain-Stokes breathing. His level of consciousness was fluctuating, with improvement with the rapid phase of breathing and deterioration during the apnea state.  The cardiologist was consulted but he did not come and several times was requested with only verbal reaction by telephone, without seeing what is happening in the stage.

The patient was put in ventilator at 3.00 a.m. the morning of 03-June-2017. The cardiac sounds were muffled and he was in hypotension. CPR was done twice. During this time the CSF in the external drain in the left side was transmitting the cardio-pulmonary pulsation, and with difficulty it was possible to feel the carotid pulse. Dopamine mega doses did not help elevate his BP which was all the time 80/50 mm Hg. 

The patient died at 7.45 a.m. 

The patient was severely critical and his age with severe cardiac failure and the severe compression of the hematomas with the rapid deterioration of his status enforced us to perform surgery as soon as possible.

Even with Plavix, if the patient was operated 3 days ago the level of mortality could be less than with recent situation.

A hard lesson, is to ask for a reliable cardiologist, because the essential factor for his death is the myocardial infarction. In the future if the relatives put there terms of asking for foreign specialists, it better to tell them to go to another hospital to avoid such situation.

What if you face the same situation in the future. I will react the same, so as not to blame myself that his death was due to the hematomas. At least I am feeling no gilt when we face the God.