The 62 y/o man was brought to our ER
on 4/3 due to severe headache for 3 days.
He had been a case of
traumatic C-spine injury in 1985 s/p op at CGMH. He had C4 quadriparesis
due to opacified posterior longitudival ligament months later, and he
underwent laminectomy of C2, C6, and C7 at our hospital in 1987.
After operation, he can stand for a while with assistance of
his family, and quadriparesis improved a little.
However, hypersomnia and poor cough ability ( his family should
give him an abdominal thrust to complete a cough process)
were noted. He underwent rehabilitation training in our
rehab. department in 1987, and then he got regular follow-up at that OPD.
He was
brought to our ER on 4/3 for severe headache for 3 days. The
initial vital sign were as follows: BP 203/129, PR 80, BT
37.3, and SpO2 94%. Nifedipine was prescribed at first, and
the follow-up BP was 161/99. However, sudden onset of apnea, lip cyanosis,
and consciousness loss developed. He underwent endotracheal
intubation. The initial ECG tracing showed bradycardia,
and it returned to normal sinus rhythm after 1 amp of atropine.
Leukocytosis, and increased infiltrate over RUL of CxR were
noted.(圖一) He underwent a non-contrast head
CT and it revealed hydrocephalus and diffuse brain
swelling.(圖二、圖三)
He was then transferred to MICU for further care.
Physically, his
consciousness was clear on arrival to MICU. The vital signs
were as follows: BP 186/90, T/P/R: 36.5/74/20. His conjunctiva
was not pale, his neck was supple, and his heart sound was
regular without murmur. The breath sound revealed crackles
over right lung, no wheeze, and diffuse rhonchi. His abdomen
was soft and flat, and he can move his extremities freely. The
neurological status was similar to his usual condition.
Laboratory:
|
WBC |
RBC |
Hb |
Hct |
MCV |
MCH |
MCHC |
PLT |
0890403 |
18.75 |
3.86 |
12.6 |
36.1 |
93.5 |
32.6 |
34.9 |
112.0 |
0890409 |
13.66 |
3.19 |
10.1 |
30.5 |
95.6 |
31.7 |
33.1 |
121.0 |
|
PT |
PT Cont |
PTT |
PTT Cont |
INR |
0890403(1404) |
14.5 |
12.6 |
42.5 |
38.5 |
1.2 |
|
GLU |
UN |
CRE |
Na |
K |
Cl |
T-BIL |
0890403 |
125.0 |
21.0 |
1.6 |
137.0 |
3.2 |
101.0 |
1.6 |
|
Ca |
Mg |
P |
AST |
CK |
CK-MB |
0890403 |
2.13 |
0.72 |
2.5 |
37.0 |
200.0 |
11.0 |
|
TP |
ALB |
GLO |
T-BIL |
D-BIL |
AST |
ALT |
ALP |
0890405 |
6.0 |
3.1 |
2.9 |
|
|
|
|
|
0890417 |
6.7 |
3.2 |
3.5 |
0.6 |
0.3 |
40.0 |
59.0 |
342.0 |
|
GGT |
UN |
CRE |
UA |
Na |
K |
Ca |
Mg |
0890417 |
216.0 |
38.1 |
2.3 |
5.3 |
133.0 |
4.2 |
2.06 |
1.1 |
GLU AC 122 (4/17)
CSF |
Appearance |
AFStain(AF) |
Gram's(GS) |
0890405 (1440) |
W;C |
- |
Nofound |
檢 體 : C.S.F.
項 目 |
Appearance |
Pandy's |
None-Apelt |
CellCount |
L/N |
0890405 (1440) |
W;C |
+ |
- |
3 |
0/3 |
0890408(1634) |
R;TT |
W+ |
- |
28 |
11 |
0890410 (1800) |
Y;C |
- |
- |
5 |
0/5 |
項 目 |
Sugar |
|
0890405 (1440) |
40-50 |
|
0890408 (1634) |
11/17 |
|
0890410 (1800) |
>50 |
|
|
PH |
PCO2 |
PO2 |
HCO3 |
BaseExcess |
0890403 (1401) |
7.44 |
32.4 |
80.6 |
21.7 |
-1.3 |
0890406 (0505) |
7.42 |
36.0 |
117.6 |
22.8 |
-0.9 |
0890409 (0515) |
7.38 |
32.3 |
80.7 |
18.7 |
-5.2 |
0890412 (0519) |
7.37 |
38.8 |
133.0 |
21.8 |
-2.7 |
0890415 (0520) |
7.41 |
37.7 |
122.4 |
23.3 |
-0.6 |
(Course and treatment): He was
treated as pneumonia initially with Unasyn. A neurosurgeon was
consulted, and brain atrophy with ventriculomegaly was impressed initially.
His dyspnea improved soon, and he was
extubated on Apr 3. However, drowsy consciousness, progressive hypoxemia, and profuse
sputum were noted on 4/4. He
underwent re-intubation for hypoxemic respiratory failure ( ABG 7.45/39.6/49.8/27.1/3.3)
and airway protection. A lumbar puncture
was performed. The open pressure was 550 mmH2O. Emergent
ventriculostomy with right side EVD(Extraven-tricular drainage) was performed
in the early morning of Apr 5. His consciousness regained at that
night. Vancomycin was given for suspected post-op ventriculitis. Paroxymal Af
was noted during ICU stay, and it was
converted to NSR by propafenone. We started EVD weaning 7 days
after ventriculostomy, and a follow-up brain CT revealed improved
brain swelling. EVD was removed on 4/10. We constructed
end-tidal CO2, cough power, and glascow coma scale as his ventilator weaning
parameter in addition to usual ones. Friquent abdominal thrusts and
束腹帶were applied to increased his cough power, and intermittent
positive pressure ventilator was performed to prevent hypoventilation. His condition
became stable, and he was extubated smoothly on 4/14.
We had consulted a neurologist, and initially communicating type normal
pressure hydrocephalus was impressed. Head MRI with CSF dynamic study to
determine shunt or no shunt will be arranged at general ward,
and Diamox was prescribed to reduce CSF production.
病案分析
此病人是個 quadriplegia, 以
severe headache 做initial presentation , 在ER 有一個奇怪的consciousness loss,因此而導致
CPR,F/U brain CT 看起來有厲害的 brain edema, 卻沒有明顯的 focal lesion,
為了證實病人確實有 IICP, 我們冒險做 lumbar puncture, 得到一個確實非常高的ICP,
外科才願意做drainage of CSF; 而在IICP relieve 後, 在 weaning 的過程中,
這種病人除了需要一般的weaning parameter做monitor, 還需 monitor cough power 和
End-tidal CO2, 而且需要一些特殊的 procedure 來幫助病人weaning. 此 case 除了討論一般
headache 的differential diagnosis, lumbar puncture 的時機, 如果一定得做,
臨床又強烈懷疑 IICP, 可一面給予 osmotherapy (ex: Mannitol),再做 lumbar
puncture, 如果得到非常高的數值, 流幾滴做必要的檢查, 而非所有的 routine 都做.
第二個討論的重點在於high cervical cord injury patient , weaning 時需注意事項.
此 case 由 MRI finding 得到最後診斷為 Cerebellar ischemic stroke with
aqueduct obstruction, complicated with hydrocephalus.(圖四) |