It was thought that Mr. C’s muscle weakness could be explained by hypokalemic periodic paralysis, and a potassium replacement was advised. Potassium was replaced, and slight improvement of weakness and generalized medical condition was noted by the next day.

But on the third day, Mr. C had a sudden setback with worsening weakness and slurred speech. He also developed bilateral nystagmus and had focal seizures of the left upper extremity. He was transferred to our hospital.

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Mr. C had another seizure involving the bilateral upper extremities and was postictal on presentation. He was drowsy and complaining of headache and reduced hearing in his right ear and was unable to cooperate with us for a complete physical examination.

The clinical exam revealed bilateral nystagmus. Meningeal signs were absent. Mr. C had generalized weakness, right facial weakness, and normal tone and deep-tendon reflexes.

The neurologist started Mr. C on levetiracetam (Keppra) and ordered an EEG/MRI of the brain.

MRI revealed a right cerebellar stroke with right temporo-parietal cortical involvement (Figure 2). Vertebral dissection/embolization was considered as a possible etiology.

Mr. C was started on a heparin drip and was transferred to the ICU pending workup (hypercoagulable state, CT angiography of the head, and transesophageal echocardiogram).

CT angiogram of the head/neck obtained the next day revealed severe vertebral artery stenosis at level C6 with 1.0- to 1.5-cm area of focal dissection (Figure 3).

Mr. C proceeded to develop an intracranial bleed, mass effect, and hydrocephalus with resultant craniotomy, and subsequent placement of a ventriculoperitoneal shunt, intubation, aspiration pneumonia, and a prolonged ICU course. The patient showed slow improvement and was transferred to an acute rehabilitation facility after four weeks. Mr. C’s final neurologic deficits included diplopia that improved with the use of an eye patch, reduced right-side hearing, and a tendency to seizure that was controlled with valproic acid. He underwent a tracheostomy for airway protection and percutaneous endoscopic gastrostomy for dysphagia.