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Grand Rounds 24 March 2005

Grand Rounds 24 March 2005. From the groin to the brain - a surgical saga. Dr Andre Loiselle Neurology Registrar. Case Presentation. Mr. R.M. 73 years old. Presenting Complaint. Started with wife remarking “you need to do something about that lump in your groin”.

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Grand Rounds 24 March 2005

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  1. Grand Rounds24 March 2005 From the groin to the brain - a surgical saga. Dr Andre Loiselle Neurology Registrar

  2. Case Presentation Mr. R.M. 73 years old

  3. Presenting Complaint • Started with wife remarking “you need to do something about that lump in your groin”

  4. History of Presenting Complaint • Pre-operative investigations for planned hernia repair revealed abnormal ECG and then stress test • Abnormal Cardiac angiogram • Went on to have coronary artery bypass grafting • Started on aspirin

  5. Slurred speech noted post operatively, but not investigated • Wife noted he wasn’t as bright mentally during the stay • Nausea and abdominal pain for 2/7 • discharged home day 10 post CABG • That evening wife noted return of slurred speech • Went to bed unwell

  6. Neurological Diagnosis? • A. Toxic/metabolic delerium • B. Perioperative cerebral microembolism • C. Anaemia causing cerebral ischaemia • D. Perioperative hypotension with cerebral hypoperfusion • E. Alcohol withdrawal

  7. Answer • B. Cerebral microembolism

  8. Woke with 400 –500 ml coffee ground vomit and dark stool • Further 100 –200 ml vomit when ambo’s arrived • Taken to Maitland hospital • Transfused 2 units RBCs • Transferred to John Hunter Hospital

  9. Previous Medical History • Type II diabetes – fairly well controlled on gliclazide and metformin • Hypercholesterolaemia – on gemfibrizol • asthma

  10. Social History • Ex-magistrate • Lives with wife • Non-smoker • Occasional alcohol

  11. O/E in A&E • Alert • afebrile • Pulse 83, reg • BP 140/72 • Cardiovascular and Respiratory examination unremarkable

  12. Abdominal examination - Mild epigastric tenderness • No rebound or guarding • No organomegaly • PR – soft brown stool

  13. Neurological Examination • Dysarthria • No facial asymmetry • No long tract signs • Plantars withdrew

  14. Gastroenterological Clinical Diagnosis? • A. Bleeding Peptic Ulcer • B. Bleeding Oesphageal varix • C. Gastritis • D. Dieulafoy’s • E. Mallory Weiss Tear

  15. Answer: • A : Provisional diagnosis of bleeding Duodenal Ulcer

  16. Initial Investigation? • A. Endoscopy • B. ECG and Cardiac Enzymes • C. CT brain • D. MRI brain • E. FBC

  17. Answer • E. FBC • (? Just Hb)

  18. Bloods • WCC 17.9 Ne 14.1 Hb 70 Plts 161 • Urea 9.2 other UEC normal • Prot 51 alb 20 bili 21 other LFTs normal • Amylase 21 • PT 14 APTT 30

  19. Subsequent Management • A. Blood Transfusion • B. IV Omeprazole • C. Endoscopy • D. CT head • E. All of the above

  20. Initial Management • Answer: E all of the above

  21. Administration of Omeprazole? • A. Orally, daily • B. Orally BD • C. Intravenous • D. Intravenous infusion • E. PR

  22. Answer • C. Intravenous

  23. IV omeprazole • Oral medications withheld • Blood transfusion • Gastroscopy showed huge DU but no actively bleeding focus • Triple therapy for H.Pylori recommended • Noted to be persistently dysarthric • CT head performed

  24. CT Findings? • A. Multiple arterial territory strokes • B. Solitary Acute ( <24 hours) Right occipital stroke • C. Solitary Subacute Right occipital stroke • D. Bilateral posterior circulation strokes only • E. Normal

  25. CT Head

  26. CT Findings? • A. Multiple arterial territory strokes • B. Solitary Acute ( <24 hours) Right occipital stroke • C. Solitary Subacute Right occipital stroke • D. Bilateral posterior circulation strokes only • E. Normal

  27. Answer: A. Multiple arterial territory subacute strokes

  28. Neurology Referral • Team arrived as patient just put back to bed • Unable to talk • Appeared to understand speech • Unable to move right face, arm or leg • Weak left face, arm and leg • Within 5 minutes – partial recovery

  29. O/E 5 minutes later • Dysarthric • Hypophonic • No dysphasia • Normal visual fields • Pupils small but reactive • Bilateral impairment of eye abduction • Bilateral horizontal gaze evoked and upbeat nystagmus

  30. Other cranial nerves normal • Limb tone normal • Mild generalised weakness • Reflexes brisk normal • Plantars extensor • Bilateral limb incoordination R>L

  31. What the? • Closest Anatomical Localisation? • A. Left Fronto-parietal • B. Left Lateral Medulla • C. Right Occipital • D. Bilateral Pontine • E. Upper Cervical Cord

  32. Answer • D. Bilateral Pontine • although probably more extensive – hypophonia suggests medullary involvement and upbeat nystagmus is classically midbrain involvement

  33. Next Investigation? • A. Repeat CT head • B. EEG • C. MRI and MR angiogram • D. CT angiogram • E. Psychiatry consult

  34. Answer • D. CT Angiogram

  35. How’s your Neurovascular Anatomy? • CTA shows: • A. Occluded Basilar artery • B. Occluded Distal Right vertebral • C. A & B • D. Occluded Right Posterior Cerberal artery • E. Occluded Left PICA

  36. How’s your Neurovascular Anatomy? • CTA shows: • A. Occluded Basilar artery • B. Occluded Distal Right vertebral • C. A & B • D. Occluded Right Posterior Cerberal artery • E. Occluded Left PICA

  37. Answer • C. Occluded distal Right vertebral artery, and occluded proximal basilar artery with some retrograde filling

  38. Treatment? • A. Antiplatelet therapy • B. Anticoagulation • C. Thrombolysis • D. Stent • E. All of the above

  39. Answer • B. Anticoagulation

  40. Cautiously heparinised • Following day became unresponsive, agonal respiration, in rapid AF but BP “stable” • GCS 3/15 • Intubated • 10 minutes after arrival to ICU – opened eyes to voice and small movements of hands and feet

  41. Repeat non-contrast CT – evolving changes only • Further episodes of tetraparesis on sitting up • Also occurred if BP <150 systolic • Episode fewer when started on IV noradrenaline • Changed to oral fludrocortisone

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