ICU update -Neuro critical

care
30/05/2016

Case 1

A 75 yr old male was apparently asymptomatic until

45 minutes back when he suddenly developed
weakness in the right upper and lower arm
,associated with slurring of speech.not associated
with fever,headache or head trauma.he had h/o of
old CVA in october 2014 ,right sided and he almost
completely recovered . Not a known diabetic or HTN
Past Medical and Surgical History
:
CVA lenticulostriate territory infarct in oct 2014
case informed to Dr MK singh advised emergency
MRI and if s/o ischemic Stroke plan thrombolysis

 at the time of admission his BP 170/120;

he was immediately shifted to MRI brain which
showed left thalamic hemorrhagic stroke
shiftef to ICU for further management
neurological examination
conscious;oriented
mild slurred speech
right upper and lowerlimb dense hemiplegia

 On admission to ICU started on

Antiedema and antiepileptics
Power in the Rt upperlimb 2/5
Since There is no Mass effect antiedema
measures stopped but patient showed
signs of decreased power in the right
upperlimb to 0/5 so decided to give 3%NS
continuous infusion @15ml/hr power
improved to 2/5 so attributed this
differential response to edema related

today he is hemodyanmically stable

RT UL power 2/5
LL-2/5
made to sit out
and was planned for shift to ward

Case 2
70/F
Known case of depressive psychosis and
osa recent admission with mood
disturbances presented with 3 episodes of
seizures since day prior to admission and
h/o constipation.
No h/o fever, breathlessness
K/C/O DM;HTN;OSA
immediately shifted for MRI brain epilepsy
protocol

MRI Brain+contrast
RIGHT FRONTAL \T\
INSULAR CORTICAL
HYPERINTESITY IN
FLAIR \T\ DWI - TO
RULE OUT HERPES
ENCEPHALITIS.

lumbar puncture attempted but couldnt

be done because sevre morbid obesity
and difficulty in positioning
so strated on Ceftriaxone +levipil and
plan to start acyclovir if no response
she continued to have partial focal
seizures regularly once an hour and
was started on Valproate started to
become epileptia partialis continua and
was strated on Lancosamide and was
intubated in view of still persistent
seizures

 she was started on Midazolam infusion but EEG

was still showing seizure spikes despite maximal
dose of infusion so switched over to thiopentone
burst supression which was also not achieved
@ a dose of 105mg/hr but cause marked
bradycardia and hypotension requiring decrease
of dosage
thiopentone @90mg/hr+4 AED still shows NCSE
started on steroid and acyclovir

 despite 48hrs of therapy she still persisted

to have seizures in continuous EEG
monitoing
so was started on immunoglobulin for a
provisional autoimmune vasculitic cause
ANA profile came negative antibody
IVIG contd for a period of 5 days And at
the fag end off therapy patient had
CLINICAL AND EEG absence of seizures

 started to decrease thiopentone infusion

and stopped by day 7
but she persisted to be drowsy for next
72hrs with repeated attempts of failed SBT
attempts so planned for elective
Tracheostomy.and percutaneous trach
was done over thext 5 days she was
gradually weaned over to tpiece and was
supported with BIPAP overnight

meanwhile in the ward she

underwent PET CT to r/o any
cryptic lesions which was
reported to be

Focal hypermetabolism in
right frontal lobe with no
morphological abnormality on
CT scan. In correlation with
MRI features are suggestive of
focal encephalitis.
Increased FDG uptake in the
anorectal region - suggested
clinical correlation.
Hematoma in the pelvis on
the right side.

 clinically she is conscious;oriented;obeying had

a desaturation on saturday evening and was
rushed back to ICU had a partial tube block and
was given agressive chest physio and thorough
suctioning done and was ventilated overnight
throughout yesterday she was on PS and in the
night kept back on her bipap
Plan to shift to ward today and over the next
week plan to wean off tracheostomy

Case 3

21/M Weakness of both upper and lower limb since evening {25/5}
neck pain since 2-3 days .
History of Presenting Illness :
Patient was apparently normal
till 2-3 days back ,then he developed follwing symptomps
-pain in the neck since 2-3 days ,insidious onset and increasing
intensity gradually,aggravated on neck movements and no relieving
factors .

Weekness of right upper limb and lower limb at around 5.30 pm

today,followed by weekness of left lower limb ,then left upper limb .
No headache ,vomiting ,seizure ,fever ,chest pain ,breathing
difficulty and trauma
intially taken to local hospital at around 7pm and reffered here for
further management
came to our hospital by 12Am

examination in ER

Moderately built and nourished

no anemia ,cyanosis ,jaundice,clubbing and pedal edema .
Respiratory System
:
Bae+.
Cardiovascular System
:
S1s2+.
Abdomen
:
Soft ,non tender,and no megaly.

Neurological

power -1/5 in right upper and lower limb

2/5 in left lower limb
3/5 in left upper limb
tone -normal in all 4 limbs
bulk-normal
reflexes -biceps ,triceps ,knee and ankle reflexes -normal on either sides
plantar -equvocal on either sides .
Touch sensation + on all 4 limbs
pain senasation absent on all 4 limbs
joint position +
bowel and bladder normal as of now

Coherent
NO NECK RIGIDITY

 provisional diagnosis
cervical cord lesion?transversemyelitis
?CVA

MRI brain and cervical cord

MRI brain WNl
MRI C spine:- INTRAMEDULLARY HEMORHAGE AT C4-5-6
LEVEL. TO RULE OUT AV MALFORMATION. ADVISE CONTRAST
STUDY. CATHETER SPINAL ANGIO WITH DSA FOR FURTHER
EVALUATION.

he was started on Steroids solumedrol 1 gm BD

 DSA done by interventional radiologist

B/L ICA,ECA, subclavian, vertebrals are
normal.
B/L T4 to L4 spinal arteries are normal.
Artery of Adamkiewicz is arising from left L2.
B/L iliac arteries are normal.
No vascular abnormality detected.

 Neurosurgeon consultation obtained

Meanwhile he started to have difficulty in
breathing decreased SBC{single breath
count};bradycardia due to ascending cord
edema and was electively intubated and was
started on orciprenaline
family came late in the night explained about the
prognosis

 Next day had MDT meeting explained

pros and cons of treatment options they
have opted for conservative management
After two days underwent elective
percutaneous tracheostomy yesterday
uneventful;off sedation
once he is fully awake he was subjected to
SBT for 4hrs in the late afternoon became
tachypneic kept back on CMV

case 4
23 Y M K/C/O CKD status post allorgraft
recipient (Feb 2016) who was discharged day
before yesterday after getting treatment for
urosepsis/LRTI/Febrile Neutropenia in a stable
condition presented with fever, headahce since
yesterday night.
Pt on presenting to ER had facial muscle
twitches, sudden onset and lasted for 40
seconds.
No H/O Vomitings, Loose stools, seizures, pain
abdomen.

Past History
Post transplant he had a antibody mediated rejection
Required Plasmapheresis
Had Septicemia And UTI with Klebsiella treated with
Meropenem
slowly he became better Gradually started to produce
urine and creatinine decreased and was maintaining
around 2 with good urine output
he was on standard immunosupression with
steroid+tacrolimus and standard antimicrobial
prophylaxis in the interim period
he was diagnosed as PTDM recently

 In view of new onset seizures he was

imediately sent to radiology for CT scan
which showed ill defined iso to
hypoodense lesions in upper brain stem
and right parietal lobes with minimal mass
effect was advised MRI with contrast for
definitive diagnosis

ICU

conscious;oriented
Signs of Raised ICP with gaze palsy
Alterd sensorium+
no FND
headache+
no menigeal signs
came up with working diagnosis of Fungal abscess in view of
immunosupression;Neutropenia prior;And persistent fever
for>4weeks despite Antibiotics as per c/s
D/w Dr Dhanunajay ;Dr Sashi kiran & Radiology team planned for
MRI with contrast followed by Ct chest followed by Lumbar puncture
for CSF analysis followed by antifungals
rationale fungal will be definitively disseminated picture

MRI
*Right frontal heterogeneous lesion with
central arterial like opacification and
surrounding edema.
Findings are consistent with fungal
abscess with underlying mycotic
aneurysm.
Differentials include Hematoma with
aneurysm.

CT Chest
*Multiple varying sized hyperdense lesion
in the both lungs especially in the upper
lobe with surrounding ground glass
appearance.
*Multiple lung lesion with pleural effusion,
pericardial effusion, ascites and enlarged
lymph nodes.
Findings are most likely of infective etiology
like fungus.

lumbar puncture

CSF Protein
CSF Glucose
Chloride Fluid

81 mg/dL
59 mg/dl
113 Millimol per liter

TC AND DC, BODY FLUID

Lymphocytes (Fluid)100 %

Neutrophils (Fluid)
-- %

Cell Count (Fluid) 4 Cells/cumm

gram stain;KOH mount ;Fungal c/s Indian ink Were
pending

 Started on Caspofungin and adjusted

Tacrolimus dosage
Next day in the ICU he was anuric
overnight with Creatinine 2.6 and K+7.4
startedon anti hyperkalemic measures and
was immediately subjected to
HemoDialysis
Post HD Abg k+3.36
Awaiting for c/s and KOH mount report
from microbiology

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