London, United Kingdom 2013 Poster Session Red Cerebrovasc Dis 2013; 35 (suppl 3)1-854 353 136 Interesting and challenging cases Life-threatening Attacks of Respiratory Arrest and Hemodynamic Instability in a Patient with Wallenberg Syndrome C. Togay Işıkay1, F. Delen2, M.H. Sorgun3, A. Bingöl4 Ankara University Faculty of Medicine Department of Neurology, Ankara, TURKEY1, Ankara University Faculty of Medicine Department of Neurology, Ankara, TURKEY2, Ankara University Faculty of Medicine Department of Neurology, Ankara, TURKEY3, Ankara University Faculty of Medicine Department of Neurology, Ankara, TURKEY4 Background: Paroxysmal attacks of respiratory arrest and vasomotor instability are very rare after lateral medul-lary infarction (Wallerberg syndrome). In this report, we describe an uncommon case of Wallenberg syndrome who presented with classical findings of the disease and developed recurrent attacks of respiratory arrest and bradycardia on sleep two weeks after his admission. Case Report: A 55-year-old man was admitted to the Stroke Unit with the acute onset of vertigo, vomiting, severe dysphagia and ataxic gate that started one week ago. He was referred from another city where he was hospitalised in an intensive care unit and intubated two times and stayed on mechanical venti-lation for a few days. He was extubated on discharge and referred to our hospital for further inves-tigation and treatment. He had chronic hypertension and hyperlipidemia in the medical history. The physical examination was normal. The neurological examination revealed dysphonic and dysarthric speech, left Horner syndrome, decreased gag reflex on the left, left-sided dysmetria and ataxic gate. Blood tests including biochemistry, blood counts, and thyroid functions, electrocardiography and chest x-ray were unremarkable. Diffusion weighted images showed left lateral medullary infarction extending to cerebellum. Cerebral angiography displayed subtotal occlusion of the left distal verte-bral artery. Two weeks after his admission, the patient complained of anxiety and insomnia and psy-chotropic agents including paroxetine and quetiapine started. After the first dose of these agents, the patient developed respiratory arrest and bradycardia on sleep and required mechanical ventilation. He required extended mechanical ventilation due to recurrent attacks of respiratory arrest. Conclusion: Even it is very uncommon, it should be remembered that Wallenberg syndrome may cause paroxys-mal respiratory arrest and vasomotor instability which may be life-threatening. Psychtropic agents like quetiapine may trigger these attacks and should be avoided in patients with medullary infarc-tions. 137 Interesting and challenging cases Beware the stroke mimic O. Pathak1, L. Brawn2, B. Vincent3 Stroke Team, Northampton General Hospital, Cliftonville, Northampton. NN1 5BD, Northampton, UNITED KINGDOM1, Stroke Team, Northampton General Hospital, Cliftonville, Northampton., Northampton, UNITED KINGDOM2, Stroke Team, Northampton General Hospital, Cliftonville, Northampton., Northampton, UNITED KINGDOM3 The “FAST” campaign encourages prompt symptom recognition and management. The temptation to get “carried away” in this momentum is great but the following outlines a case with an atypical course and salient learning point. Mr RC, 68 year old retired and active gentlemen presents with a 24 hour history of right facial droop and expressive dysphasia preceded by a 4 day history of lethargy. Pyrexial with no limb neurology on admission, with a raised CRP and mild neutrophilia. On warfarin (INR 1.4) for a metallic aortic valve. Admission CT head demonstrated sulcul effacement in the left parietal lobe. Managed as a left parietal infarct secondary to cardiac emboli. Neurology progressed with multiple seizure events requiring phenytoin infusion. Repeat CT revealed apparent maturation of a left temporoparietal in-farct and seizures attributed to this. The pyrexia continued and echocardiogram suggested aortic valve vegetations and antibiotics for endocarditis commenced. Subsequent blood and urine cultures and transoesophageal echocardiogram were negative. Inflammatory markers remained raised de-spite the antibiotic cover therefore a lumbar puncture was performed. This demonstrated raised CSF protein and lymphocytosis. Aciclovir was initiated for suspected encephalitis and inflammatory markers and pyrexia settled. CSF PCR confirmed HSV infection. Repeat CT brain imaging demon-strated “textbook” images of HSV encephalitis, with a route tracking through the limbic system with basal ganglia sparing. Over 6 weeks, he progressed to supervised mobility and feeding but residual cognitive impairment and challenging behaviour required neurorehabilitation input. This case demonstrates the need to consider stroke mimics even in those histories that seem straight forward. HSV encephalitis is an important differential diagnosis in those with raised inflammatory markers and temporoparietal ischaemia on CT imaging as early management impacts on long term outcome and disability.
Karger_ESC London_2013
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