Left middle cerebral artery infarct in a young man with Crohn's disease

Autor: Dan Harris
Rok vydání: 2009
Předmět:
Zdroj: Journal of the Royal Society of Medicine. 102:443-444
ISSN: 1758-1095
0141-0768
Popis: A 38-year-old man was brought to A&E having collapsed at home after complaining of right-hand paraesthesia and discolouration. A self-employed plumber and smoker, he had been diagnosed with Crohn’s disease aged 18 years although he was not receiving any treatment at this time. On arrival 35 minutes post onset of symptoms he had a right-sided weakness plus inattention. His airway was patent, he was ventilating spontaneously (RR 24 breaths/min) and he was haemodynamically stable (pulse 90 bpm sinus rhythm, NIBP 115/65 mmHg). His Glasgow Coma Score (GCS) was 11/15 (Eyes 4, Verbal 2, Motor 5 [R]) with right-sided hypotonia and weakness (3/5) and upward right plantar reflex. Four minutes post arrival he vomited and dropped his GCS to 8/15 (Eyes 2, Verbal 1, Motor 5 [R]) which necessitated a rapid sequence induction of anaesthesia (propofol and suxamethonium) and tracheal intubation. The digits of his right hand were markedly discoloured with a capillary refill time of 5 seconds. His radial pulse was weakly palpable and ulnar pulse detectable on doppler examination. CT head with contrast performed 65 minutes post onset of symptoms showed low attenuation involving the insular cortex and lentiform nucleus with associated sulcal effacement consistent with an acute left middle cerebral artery territory infarct and no evidence of haemorrhage (Figure 1). He was given Alteplase (81 mg) 85 minutes post onset. A transthoracic echocardiogram (TTE) performed in A&E showed good biventricular function, no clots or masses, a normal aortic root and arch and no obvious patent foramen ovale although TTE cannot safely exclude such an abnormality. A repeat CT performed 8 hours post onset showed an increase in low attenuation. A CT aortogram performed to examine for great vessel dissection or occlusion found no abnormalities. Venous blood tests suggested probable active low grade Crohn’s disease despite his wife’s reports of no recent episodes (Hb 10.0 g/dL, MCV 70.9 fl, Plt 481 × 10/L, Alb 25 g/L, CRP 86 mg/L, Mg 0.67 mmol/L). On the ITU 23 hours post onset he developed signs of raised intracranial pressure (Pulse 65 bpm, IBP 200/100 mmHg). CT showed infarct progression with extensive attenuation reduction and accompanying mass effect with midline shift but still no haemorrhage. Brainstem testing was later performed with family present and he died 34 hours post onset of symptoms.
Databáze: OpenAIRE
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