Grand Rounds 24 March 2005

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Grand Rounds24 March 2005

• From the groin to the brain - a surgical saga.
• Dr Andre Loiselle
• Neurology Registrar

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Case Presentation

• Mr. R.M.
• 73 years old

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Presenting Complaint

• Started with wife remarking you need to do
  something about that lump in your groin

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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

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• Slurred speech noted post operatively, but not
  investigated
• Wife noted he wasnt 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

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Neurological Diagnosis?

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

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Answer

• B. Cerebral microembolism

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

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Previous Medical History

• Type II diabetes fairly well controlled on
  gliclazide and metformin
• Hypercholesterolaemia on gemfibrizol
• asthma

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Social History

• Ex-magistrate
• Lives with wife
• Non-smoker
• Occasional alcohol

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O/E in AE

• Alert
• afebrile
• Pulse 83, reg
• BP 140/72
• Cardiovascular and Respiratory examination
  unremarkable

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

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Neurological Examination

• Dysarthria
• No facial asymmetry
• No long tract signs
• Plantars withdrew

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Gastroenterological Clinical Diagnosis?

• A. Bleeding Peptic Ulcer
• B. Bleeding Oesphageal varix
• C. Gastritis
• D. Dieulafoys
• E. Mallory Weiss Tear

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Answer

• A Provisional diagnosis of bleeding Duodenal
  Ulcer

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Initial Investigation?

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

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Answer

• E. FBC
• (? Just Hb)

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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

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Subsequent Management

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

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Initial Management

• Answer E all of the above

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Administration of Omeprazole?

• A. Orally, daily
• B. Orally BD
• C. Intravenous
• D. Intravenous infusion
• E. PR

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Answer

• C. Intravenous

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• 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

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CT Findings?

• A. Multiple arterial territory strokes
• B. Solitary Acute ( lt24 hours) Right occipital
  stroke
• C. Solitary Subacute Right occipital stroke
• D. Bilateral posterior circulation strokes
  only
• E. Normal

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CT Head
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CT Findings?

• A. Multiple arterial territory strokes
• B. Solitary Acute ( lt24 hours) Right occipital
  stroke
• C. Solitary Subacute Right occipital stroke
• D. Bilateral posterior circulation strokes
  only
• E. Normal

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• Answer A. Multiple arterial territory subacute
  strokes

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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

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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

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• Other cranial nerves normal
• Limb tone normal
• Mild generalised weakness
• Reflexes brisk normal
• Plantars extensor
• Bilateral limb incoordination RgtL

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What the?

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

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Answer

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

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Next Investigation?

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

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Answer

• D. CT Angiogram

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Hows 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

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Hows 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

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Answer

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

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Treatment?

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

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Answer

• B. Anticoagulation

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• 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

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• Repeat non-contrast CT evolving changes only
• Further episodes of tetraparesis on sitting up
• Also occurred if BP lt150 systolic
• Episode fewer when started on IV noradrenaline
• Changed to oral fludrocortisone

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Mechanism of ongoing events?

• A. Emboli from AF
• B. Thromboembolic from occluded
  vertebrobasilar system
• C. Hypoperfusion
• D. Seizure
• E. Haemorrhages

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Answer

• C. Postural and blood pressure related
  symptoms
• Suggests brainstem hypoperfusion through a
  critically stenosed vertebrobasilar system.

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• 4 days later Platelets dropped to 40

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Aetiology of Low Platelets?

• A. HITS
• B. ITP
• C. Transfusion related
• D. Clumping
• E. Aspirin induced

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• Answer A HITS
• - ve HITS antibodies.
• Changed to lepirudin
• Over next week slowly able to maintain upright
  sitting posture but unable to stand due to
  brainstem hypoperfusion , even with BP gt120
  systolic

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Summary

• Previously fairly well 73 yr old man with
  perioperative CABG posterior circulation stroke
• CTA shows occluded right vertebral artery and
  proximal basilar
• Ongoing orthostatic brainstem ischaemia
• Complicated by GIH HITS

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Management options?

• A. Continue current management will improve
  with time
• B. Convert to oral anticoagulation
• C. Change to antiplatelet therapy
• D. Contact Denomination Specific Religious
  Advisor
• E. Revascularise

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• Answer E Revascularise.
• Transferred to RNSH under Prof. Morgan
• Surgical Procedure Performed.

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Which Surgical Procedure was Performed?

• A. Greater Occipital Artery to PICA artery
  bypass
• B. Basilar Stent
• C. Decompressive Hemicraniectomy
• D. Venous graft from proximal right vertebral
  to distal basilar
• E. None of the above

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Which Surgical Procedure was Performed?

• A. Greater Occipital Artery to PICA artery
  bypass
• B. Basilar Stent
• C. Decompressive Hemicraniectomy
• D. Venous graft from proximal right vertebral
  to distal basilar
• E. None of the above

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Answer

• A. Greater Occipital artery to PICA bypass
• Cerebral angiography / basilar stenting not
  performed due concerns re anticoagulation and
  difficult vertebral access

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Progress

• Transferred back to JHH after 3/52
• Now (3/12) mobilising with frame and assistance
• Discharged to rehabilitation

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The end