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Surgical Saga: From Groin to Brain - A Neurological Mystery

Join Dr. Andre Loiselle as he presents a complex case of a 73-year-old man with post-operative neurological complications, uncovering a journey from hernia repair to cerebral microembolism.

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Surgical Saga: From Groin to Brain - A Neurological Mystery

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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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