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AN INTERESTING CASE OF ACUTE QUADRIPARESIS

AN INTERESTING CASE OF ACUTE QUADRIPARESIS. VII MU PROF.DR.M.MUTHIAH, M.D DR.D.GANESAPANDIAN,M.D DR.G.GURUNAMASIVAYAM,M.D. History. 55 year old male patient Mr.Ramu, admitted with complaints of.. Sudden onset of giddiness and swaying followed by Loss of consciousness for 1 hour

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AN INTERESTING CASE OF ACUTE QUADRIPARESIS

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  1. AN INTERESTING CASE OF ACUTE QUADRIPARESIS VII MU PROF.DR.M.MUTHIAH, M.D DR.D.GANESAPANDIAN,M.D DR.G.GURUNAMASIVAYAM,M.D

  2. History.. • 55 year old male patient Mr.Ramu, admitted with complaints of.. • Sudden onset of giddiness and swaying followed by • Loss of consciousness for 1 hour • Weakness of all 4 limbs 5 hours

  3. Apparently normal till 5 hours ago • Sudden onset of giddiness and swaying to left side • Pt had Loss of consciousness for nearly 1 hour and on regaining consciousness found that he was unable to use any of his limbs • Pt fully conscious on admission to GRH

  4. H/O inability to move all 4 limbs. • Simultaneous involvement of all 4 limbs • Weakness more in upper limbs than lower limbs • static weakness • No H/O fasciculations/twitching • No H/O involuntary movements • H/O decreased sensation below the neck(onset along with the weakness) • No H/O root pain • H/O retention of urine+ • H/O constipation+

  5. No H/S/O cranial nerve involvement • No visual disturbances • No disturbances of facial sensation • No seizures/ speech or memory disturbances • no H/O fever

  6. No H/O chest pain • No H/O cough/ expectoration • No H/O prior recurrent syncopal attacks/ palpitations

  7. Past history • No H/O similar episodes in the past • Not a known pt of DM/HT/BA/PT/IHD/ seizures • No past H/O TIA • No H/O major hospitalisation in the past

  8. Personal history • Takes mixed diet • Manual labourer by ocupation • Not a known smoker or alcoholic

  9. On examination • Elderly male • Moderately built and nourished • Conscious and oriented • Comfortable at rest • No pallor/icterus/clubbing/cyanosis/ • pedal edema/lymphadenopathy • No rash

  10. Vital data • PR: 86/min, regular, normal volume. Felt in all palpable vessels, both carotids equal • BP: 130/80 mmHg in RUL • RR: 16/min • Temp: normal

  11. Examination of nervous system • Higher mental function: normal, right handed individual • Cranial nerves: normal • Pupils: 3mm reacting to light equally on both sides • Gaze evoked nystagmus present bilaterally more to left side • Facial sensation normal • Fundus: normal

  12. Spinomotor system.. Day 1

  13. Reflexes.. day1

  14. Spinomotor system.. day4

  15. Reflexes.. day4

  16. Sensory system… All sensory disturbances below C5 level

  17. No involuntary movements • No fasciculations • Coordination: could not be tested • Cerebellar functions: could not be tested • Gait: could not be tested • No meningeal signs • Spine and cranium normal • Height neck ratio normal

  18. Others systems • Clinically normal

  19. Provisional diagnosis… • Acute onset spastic quadriparesis with initial spinal shock and involving pyramidal tract, anterior spinothalamic tract, sparing the dorsal column( sensory dissociation). Bladder involvement+ motor level between C3 and C5, reflex level above C5 and sensory level C5. Spinal vibration normal

  20. Neurologist’s opinion • ? Central cord syndrome • To R/O posterior circulation stroke • Suggested MRI brain

  21. Hb: 12.4gm% TC: 6700 cells/cu.mm DC:P58L40E2 ESR: 16mm/hr Peripheral smear: normal study Urinalysis: Albumin: nil Sugar: +++ Deposits: nil 24 hour urine protein excretion: 50mg/day Investigations..

  22. Blood urea: 32mg% S.creatinine: 0.8mg% Blood sugar: Admission: 345mg% FBS: 234mg% PPBS: 300mg% T.cholesterol:289mg% LDL: 210mg% VLDL: 34mg% HDL: 40mg% TGL: 265mg%

  23. Day1 Na: 138meq/L K: 4.0meq/L Cl: 100meq/L HCO3: 20meq/L Day4 Na: 140meq/L K: 4.2meq/L Cl: 98meq/L HCO3: 2meq/L Serum electrolytes

  24. Others.. • ECG: sinus rhythm, normal axis, normal study • ECHO: normal study • USG abdomen: normal study • CT brain: no significant abnormality • Ophthalmologist’s opinion: no evidence of diabetic retinopathy, no visual deficit

  25. MRI brain and spine…

  26. MRI spine… • Mild diffuse enlargement of cervical cord with intramedullary bright signal extending from C2 to T1 with minimal skip areas • Lesion predominantly located at central and anterior aspect of spinal cord • Bony structures normal • Bright signal replacing the normal flow void of left vertebral artery( S/O left vertebral artery occlusion) double lumen seen with intimal flap.. ?vertebral artery dissection with luminal thrombus • Above findings suggestive of spinal cord infarction

  27. MRI brain… • FLAIR bright signal lesion with diffuse restriction involving left cerebellum(vermis, anterolateral cerebellar hemisphere, middle and inferior cerebellar peduncle) with effacement of fourth ventricle with CPA cisterns.. Representing acute infarct( AICA and SCA territories) • Multiple chronic infarcts involving both corona radiata and centrum semiovale, biparietal, subcortical and periventricular regions)

  28. Final diagnosis.. • Type 2 diabetes mellitus with dyslipidemia • Acute spastic quadriparesis • Sensory involvement with sensory dissociation • Spinal shock recovered • As a consequence of spinal cord infarction due to ?vertebral artery thrombosis, ?vertebral artery dissection

  29. Course of illness.. • Pt treated with insulin, aspirin, clopidogrel and statins • Bladder was catheterised • Limb physiotherapy was given • Muscle power improved well • Pt was discharged after 1 week and went home walking • Catheter removed

  30. THANK YOU

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