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London, United Kingdom 2013 Poster Session Red Cerebrovasc Dis 2013; 35 (suppl 3)1-854 361 150 Interesting and challenging cases Stroke and fluctuating consciousness? Think thalamic. O. Pathak1, L. Brawn2 Stroke Team, Northampton General Hospital. Cliftonville, Northampton, UNITED KING-DOM1, Stroke Team, Northampton General Hospital. Cliftonville., Northampton, UNITED KING-DOM2 Mr JS, 73 year old retired, Indian gentleman with diabetes and presented after being found unre-sponsive. Initial GCS was 6 (M4 V1 E1) but other observations normal. A dense right sided hemiplegia and sensory inattention was apparent. Atrial fibrillation (AF) was seen on cardiac monitoring though not on subsequent ECG. His GCS improved (M6 V3 E2) and CT head – was normal. He was managed as a left cerebral infarct with a seizure event. Within hours his GCS returned to 6 with no overt seizure activity and normal observations. CT head revealed nil acute but with recurrent events IV heparin was initiated for suspected posterior circula-tion TIA events and transferred to the high dependency unit (HDU). Over 48 hours, GCS remained low attributed to cerebral oedema, post ictal state, hypoactive delir-ium and all metabolic parameters were controlled. On day 3, he “woke up” attempting to get out of bed. On examination, he was agitated and his right sided neurology continued. This upturn was not sustained and within 90 minutes his GCS was 6. He continued to have intermittent lucid episodes. IV heparin was stopped. MR brain demonstrated bilateral thalamic infarcts and MR angiogram demonstrated an artery of Percheron (PCA variant) thombus which would explain these. This was the cause of his fluctuating consciousness. A cardioembolic source was suspected but cardiac moni-toring and transoesophageal echocardiogram were normal. Autoimmune tests were requested. War-farin was initiated (AF on admission) and he progressed to discharge home with community support. We are taught that strokes nearly never cause loss of consciousness or are bilateral. When we do see low GCS with stroke disease we are quick to implicate seizures or cerebral oedema. This case reminds us to consider neuroanatomical variants which may explain the “impossible.” The artery of Percheron, present in 30% of people, supplies the thalamus bilaterally and an occlusion here causes RAS dysfunction and the above symptoms. 151 Interesting and challenging cases Locked-in syndrome – an ethical dilemma S. Carrington1, J. Birns2 Stroke Unit, Department of Ageing & Health, St Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UNITED KINGDOM1, Stroke Unit, Department of Ageing & Health, St Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UNITED KINGDOM2 A 41 year old man suffered an acute basilar artery occlusion resulting in right occipital lobe and bi-lateral brainstem infarction. 4 months later, he required ventilatory support on a critical care unit and had evidence of incomplete locked-in syndrome with quadriplegia, lower cranial nerve paralysis and anarthria with preserved consciousness, vertical eye movement and additional remnants of volun-tary movement. He had previously indicated that he would not want to continue his life if in such a position but his family and clinicians wished to ascertain whether he was able to indicate his current wishes. He consistently nodded his head for a ‘yes’ response and shook his head for ‘no’. Using part of the complex ideational material subsection of the Boston Diagnostic Aphasia Examination, he achieved correct responses 75% of the time for paired questions (Table 1) and 100% for paragraph compre-hension (each of 3-4 complex sentences at 3-4 key word level). He was able to engage in discus-sions regarding his medical care with ‘yes/no’ answers to questions specific to his current medical status and ongoing treatment (Table 2). He indicated that he wished to continue with medical treat-ment and rehabilitation, did not want to die and wanted to be resuscitated in the event of cardiorespi-ratory failure. Individuals with locked-in syndrome are extremely physically limited but have significant potential to communicate with intact consciousness and hearing. They are ‘imprisoned’ until others facilitate alternative means of communication for them to make choices and exert influence on their environ-ment. Locked-in syndrome has a poor prognosis but opinions regarding quality of life and desire to continue living vary between individuals. It is therefore essential to undertake a thorough neurolog-ical and communication assessment to ascertain preserved abilities and optimise the patient’s ability to participate in the discussion. Table 1: Paired questions with patient’s resposnse Question Non-verbal response Correct? Will a cork sink in water? No Yes Is a hammer good for cutting wood? No Yes Do two pounds of flour weigh more than one? Yes Yes Will water go through a good pair of Wellington boots? Yes No Will a stone sink in water? Yes Yes Can you use a hammer to pound nails? Yes Yes Is one pound of flour heavier than two? Yes No Will a good pair of Wellington boots keep water out? Yes Yes


Karger_ESC London_2013
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