Brain Stem Damage

[Deno]

A 68 year old enters the hospital with severe stomach pain. Found to have a large bleeding ulcer, she goes to surgery, the ulcer is removed but for some still unknown reason parts of the stomach have died off. Once inside we discovered the stomach had given way, releasing contents into the body cavity. Infection  and sepsis developed.

Through day four of treatment the patient was responsive to external stimuli, e.g. pain, touch. In order to maintain blood presure, the patient was given large amounts of fluid. Because the patient's blood vessels were not ratining fluid, the patient began to swell up with fluid just below the skin. From day four through day six no sign of response was noted. Then upon ending the sedative regiment, the patient failed to regain consciousness.

Her EKG was fine but EEG shows irratic/chaotic waves. The patient's clinical response is consistent with severe brain stem damage. We are unable to conduct MRI testing due to patient's current condition. One theory holds that the body has been sending off micro-bursts of material to the brain, thereby causing many mini strokes. However, this damage appears to be massive; as such, I ask:

Could the fluid intake have caused the stem damage from the same swelling that affected the body? As of now, the damaged stem doesn't appear to be related to BP crash/O2 issues. However, without an MRI we have no empirical imaging to even confirm the stem damage.

Any information on similar case studies will be appreciated. Could a lack of Activated Protein C be a factor?, etc. Might a BAERs test prove helpful?

[CCF-Neuro-M.D.-JT]

From the nature of the post, I assume that you are in the healthcare profession and possibly involved in this patient's care. Please keep in mind that an accurate neurological opinion cannot be given without a personal review of the patient's full history, clinical course and diagnostic studies as well as a careful neurological examination or at the very least a more in-depth description of the examination. "Erratic/chaotic waves on EEG" and "exam consistent with brainstem damage" are insufficient for someone reviewing the case to make a complete neurological impression.



Having said that, the patient's current neurological status is likely to be multifactorial: possible hypotension from the GI bleed, sepsis, electrolyte disturbances, prolonged sedation, etc... We have seen many cases that are similar in which an older patient fails to wake up after a prolonged or complicated hospital course following a GI bleed or surgery. In these cases like the one you present, the etiology is as I stated before, likely to be multifactorial.  To answer your particular question: Cerebral edema can certainly be caused by electrolyte disturbances and massive strokes/tumors, but not fluid overload generally speaking.  As for the possibliyt of multiple brainstem strokes, this can caused by  caused by hypotension (especially in the setting of intracranial arterial disease), sepsis, or endocarditis. Finally, brainstem dysfunction could be evaluated by a careful neurological examination, cold water calorics, oculocephalic maneuvers, and of course BAERs as you suggest.



If this is a real inpatient hospital case that requires neurological input, then a neurological consult should be considered. Good luck.

[morrison_PD]

It sounds as though the kidneys, aleady compromised by sepsis, were overloaded with fluids, put into kidney failure, which then, in combination with sepsis, caused brain damage evidenced by erratic electroencephalogram plus unconsciousness.



Is the patient now alive/brain damaged ? unconscious/brain dead ?

[Deno]

The patient was almost wholly non-responsive to every reflex test. She was alive, not "brain dead" insofar as EEG clearly provided wave activity. Nevertheless, because that activity remained disorganized and scattered, and because after days NO improvement in her condition manifest, she was released from her support systems by family. She developed internal bleeding and while I was sure the stomach was not the site of this bleeding, going in would have been the only way to isolate the site of hemorhage. Bottomline: a very sad case; one in which all appeared on track until the sedation was withdrawn.