CHIEF COMPLAINT: Bilateral cerebellar infarction
HISTORY OF PRESENT ILLNESS: The patient was sent over emergently from the VA by the neurologist. He apparently a couple weeks ago had a cold and was treating himself with cold symptom medications. There is also one report that he had undergone chiropractic manipulation but apparently talking with family it was not a chiropractor it was just a massage therapist and there was really no substantial manipulation of his neck. Regardless, two nights ago he said he really did not feel well at all and went to bed. He woke up at 1:00 in the morning and had significant vertigo, headache and nausea and vomiting so they did ultimately take him into the emergency room. A head computerized axial tomography scan at that time was negative. They did do a lumbar puncture to make sure he did not have any signs or symptoms of infection given the history of cold symptoms which apparently by report was negative. He was sent to the VA for further evaluation. Subsequently he has been diagnosed with cerebellar infarctions based on computerized axial tomography scans and magnetic resonance imaging scans that were performed and fortunately these are bilateral and they appear to involve the pica distribution. However the concerning things is apparently the patient yesterday was wide awake and lucid and today progressively over the day has become significantly more lethargic and developed bilateral extraocular motility defects. Because of this, they obtained a scan which shows early hydrocephalus as well as significant posterior fossa swelling.
GENERAL: He is a very lethargic patient that will arouse with stimulation. He will answer a few questions with simple yes and no answers but it sounds like he has significantly gone downhill even over the last several hours.
NEUROLOGIC: He has extraocular motility that is very hard to characterize but I do think it looks like interocular ophthalmoplegia or perhaps polycranial nerve involvement but clearly abnormal. His pupils are small and remain perhaps minimally reactive. He does seem to have diminished gag response. He does move his extremities but it is hard to get a detailed examination but Babinski is present bilaterally on exam. Gait and station were not tested.
CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Appear to be clear but the breath sound are somewhat diminished
IMPRESSION: This gentleman has the above mentioned problems. I have had a chance to look at the films. I have reviewed them with our radiologist. Initially the films were not available but they did finally show up from the VA. In the interim, since we really did not know exactly what was going on we did get a computerized axial tomography scan so we have been able to compare this. It looks like he has got fairly extensive pica infarcts of the bilateral cerebellar hemispheres. Because of this, I think we will plan doing a midline decompression in light of his deterioration where we will try to do stroke resection bilaterally and patch the dura as best we can to give it room for swelling. The patient also probably would benefit from an external ventricular drain at lest in the short-term given the significant problem that he has. I was fairly frank with the family that obviously surgery is not going to change his overall course with respect to the stroke. He will still have deficits from this even if he does survive. What surgery is is an attempt at saving his life because of the progressive swelling that he has developed and an the anticipation that this is heading downhill fast enough that he will die from the brain stem compression. They do understand that the stroke still may progress and he may be significantly disabled or even die despite doing surgery that surgery does have risks of infection, cerebrospinal fluid leakage that might require pseudomeningocele repair at a later date particularly since we may not be able to get watertight dura closure if there is significant swelling. We also did discuss the risk of intracranial hemorrhage, infection and they wished to proceed with surgical intervention.
John G. Piper, M.D.
CT HEAD WO CONTRAST
INDICATION: History of bilateral cerebellar infarcts
COMPARISON: There is no previous imaging for comparison
FINDINGS: There are areas of decreased attenuation identified in the cerebellar hemispheres bilaterally. This may represent bilateral PICA infarcts. Other etiologies for vasogenic edema cannot be excluded. The previous imagining on this patient is not available for comparison. There is compromise of the fourth ventricle. Mild hydrocephalus is consistent with mass effect.
IMPRESSION: There are areas of decreased attenuation within the cerebellar hemispheres bilaterally. By history, these represent areas of infarctions on the previous MRI examination. That examination is not available for comparison.
CT HEAD WO CONTRAST: CRANIOTOMY FOLLOW-UP