A 68-year-old right-handed man is brought by ambulance to the emergency department after his wife found him unresponsive. The wife states that her husband had not been feeling well for the last 12 hours. He woke up this morning "complaining of dizziness, neck pain, unsteadiness, and headache." As the day progressed, his symptoms worsened and he started vomiting. Towards the evening, the patient was lethargic and more confused than at his baseline. He has not had any fevers or chills.
His medical problems include poorly controlled hypertension, hyperlipidemia, ischemic stroke due to untreated high-grade left carotid artery stenosis, COPD on home oxygen, and chronic low back pain treated with oxycontin and hydrocodone. He lives with his wife and depends on her for most of his activities of daily living. For the past several months, his wife has had more difficulty taking care of him and administering his medications properly. She states that the patient has been "abusing his narcotic medications."
His temperature is 37.1 C (98.8 F), blood pressure is 170/110 mm Hg, pulse is 40/min, and oxygen saturation is 85% on room air. His general physical examination reveals a left carotid bruit, S4 gallop, and prominent expiratory wheezes with reduced air flow. On neurological examination, he appears comatose. Cranial nerve testing reveals absence of blink-to-threat, mid-position fixed and dilated pupils, absence of oculocephalic reflex, and presence of corneal, gag, and cough reflexes. Motor examination reveals extensor posturing in the upper and lower extremities. Reflexes are absent and plantar responses are mute. He does not grimace to pain.
Which of the following is the most likely etiology for this patient's presentation?

Question

A 68-year-old right-handed man is brought by ambulance to the emergency department after his wife found him unresponsive.  The wife states that her husband had not been feeling well for the last 12 hours.  He woke up this morning "complaining of dizziness, neck pain, unsteadiness, and headache."  As the day progressed, his symptoms worsened and he started vomiting.  Towards the evening, the patient was lethargic and more confused than at his baseline.  He has not had any fevers or chills.
His medical problems include poorly controlled hypertension, hyperlipidemia, ischemic stroke due to untreated high-grade left carotid artery stenosis, COPD on home oxygen, and chronic low back pain treated with oxycontin and hydrocodone.  He lives with his wife and depends on her for most of his activities of daily living.  For the past several months, his wife has had more difficulty taking care of him and administering his medications properly.  She states that the patient has been "abusing his narcotic medications."
His temperature is 37.1 C (98.8 F), blood pressure is 170/110 mm Hg, pulse is 40/min, and oxygen saturation is 85% on room air.  His general physical examination reveals a left carotid bruit, S4 gallop, and prominent expiratory wheezes with reduced air flow.  On neurological examination, he appears comatose.  Cranial nerve testing reveals absence of blink-to-threat, mid-position fixed and dilated pupils, absence of oculocephalic reflex, and presence of corneal, gag, and cough reflexes.  Motor examination reveals extensor posturing in the upper and lower extremities.  Reflexes are absent and plantar responses are mute.  He does not grimace to pain.
Which of the following is the most likely etiology for this patient's presentation?

Quizplus · Accepted Answer

11ec193a_9662_d66d_853d_7b991653e97a_MD0002_00 This patient's presentation is consistent with likely acute hypertensive cerebellar hemorrhage causing increased intracranial pressure and secondary upward transtentorial herniation. Hypertensive hemorrhages most commonly occur in the basal ganglia and thalamus. However, they can also occur in the cerebellum, pons, and even the lobar regions (~10%). Patients typically present acutely with severe headache, nausea/vomiting, vertigo, unsteadiness, and mental status changes. Space occupying lesions (e.g., hemorrhage) in the small posterior fossa can quickly obliterate the fourth ventricle to cause obstructive hydrocephalus, increased intracranial pressure (ICP), and Cushing reflex (hypertension, bradycardia, and Cheyne-Stokes breathing). The increased ICP can cause the cerebellum to herniate upwards to compress the mid-brain (areflexic pupils, impaired oculocephalics, and extensor posturing as seen in this patient), or downwards to compress the medulla oblongata (ataxic breathing, loss of gag and cough reflexes). This patient needs urgent imaging to confirm the diagnosis as well as likely surgical decompression. (Choice B) Enteroviral meningitis usually occurs in the summer/early fall and presents with severe headache, fever, malaise, and neck rigidity. However, these patients usually maintain normal mental status. (Choice C) Hypercapnia due to severe COPD exacerbation can cause headache and depressed mental status. However, it does not usually trigger a Cushing reflex or profuse vomiting. (Choice D) Middle cerebral artery occlusion usually presents with hemiparesis, but typically does not cause extensor posturing as seen in this patient. (Choice E) Opiate intoxication will typically cause pinpoint pupils, and will not trigger a Cushing reflex. Educational objective: Patients with cerebellar hemorrhage typically present acutely with severe headache, nausea/vomiting, vertigo, unsteadiness, and mental status changes. Space occupying lesions (e.g., hemorrhage) in the small posterior fossa can quickly obliterate the fourth ventricle to cause obstructive hydrocephalus, increased intracranial pressure, and Cushing reflex (hypertension, bradycardia, and Cheyne-Stokes breathing). __________ References: Cerebellar infarcts and hemorrhages. (http://www.ncbi.nlm.nih.gov/pubmed/22377889)

A 68-Year-Old Right-Handed Man Is Brought by Ambulance to the Emergency