History:
A patient in their early 50’s is brought to the ED by medics as a stroke code. Her symptoms/signs include aphasia, lethargy and rights sided weakness all of which were noted by family in the morning. LKW time was 9pm last night. Patient unable to answer questions other than her name due to severe aphasia. Medics state she vomited x 2 en route
Vital Signs & Physical Exam:
BP elevated. Flaccid right leg and arm. Lethargic but is able to follow commands with her left arm and leg as well as her face.
Initial Diagnostic Testing:
How would the most likely complication of this bleed present clinically?
- A) downward eye deviation, lethargy and bradycardia
- B) upward eye deviation, lethargy and tachycardia
- C) leftward eye deviation, twitching and fever
- D) rightward eye deviation, twitching and tachycardia
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ANSWER:
- A) downward eye deviation, lethargy and bradycardia – CORRECT – this can be present with obstructive hydrocephalus was can the rest of the Cushing reflex
- B) upward eye deviation, lethargy and tachycardia – upward eye deviation is usually intentional and can be present in pseudo-coma or pseudoseizure
- C) leftward eye deviation, twitching and fever – This could be presentation of seizure from the right hemisphere
- D) rightward eye deviation, twitching and tachycardia – seizure from stroke/bleed would cause eyes to deviate away from the bleed
CASE CONCLUSION: Forced downward eye deviation and Cushing response (HTN/wide pulse pressure, bradycardia, irregular breathing) was intermittent, likely due to intermittent obstructive hydrocephalus from blood clotting and dissolving in the 4th ventricle. She was Intubated and admitted to ICU. So far did not need a ventriculostomy
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