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Washington University Experience | VASCULAR | Cardiac Arrest Encephalopathy | 8A0 Case 8 History
Case 8 History ---- The patient was first diagnosed with spasmodic dysphonia 20 years prior to his death with brief shaking of his right hand at rest in 7 years prior to his death. Soon he developed smaller handwriting, a slow gait and he began falling. He developed excessive day time fatigue and hallucinations when he began taking ropinirole. He developed problems with word retrieval and short term memory two years before his death. Neurologic examination showed asymmetric rigidity, bradykinesia and tremor with impaired postural reflexes consistent with idiopathic Parkinson disease. Meanwhile he was tested for reversible causes of dementia which was non-revealing (normal TSH and B12). His motor symptoms remained undertreated as he could not tolerate any escalation of carbidopa/levodopa due to symptomatic orthostatic hypotension. He did not qualify for deep brain stimulator placement as overnight withholding of medication did not cause any marked worsening of symptoms, and he had no improvement with large doses of carbidopa/levodopa. However, a slow taper over 2 months and gradual escalation of carbidopa/levodopa (which he could tolerate better with taking fludrocortisone) showed about 35% improvement. He was on the regular hospital floor and was seen last by relatives. He was alert and eating supper. He was then found unresponsive and "grayish" within 2 hours. He was resuscitated and taken to the intensive care unit (ICU). His family decided to re-direct to comfort care, given his poor neurological examination and electroencephalogram (EEG) findings. He died in the evening of 4/5 (a few days after his arrest) with the clinical suspicion that terminal events were likely related to aspiration and asphyxia. ---- At autopsy his unfixed brain weighed 1620g and was edematous. Histopathology demonstrated Lewy body disease, brainstem predominant. The medulla exhibited bilateral dusky discoloration involving the vestibular and cuneate nuclei.
