Clinical Reasoning: A 61-year-old man with conjugate gaze deviation, hemiparesis, and asymmetric reflexes

A 61-year-old man with a history of alcoholic cirrhosis was transferred from an outside hospital for spontaneous bacterial peritonitis, septic shock, and respiratory failure after intubation. The patient was initially on sedation; however, more than 48 hours after the sedative was discontinued, his mental status remained depressed and he also developed new onset of conjugate rightward gaze deviation. On neurologic examination, the patient was unresponsive to verbal stimuli and sternal rub. He could not follow any command, including closing or opening eyes and squeezing hands. He had remarkable conjugate, forced eye deviation that could not be corrected to cross the midline using the vestibulo-ocular reflex. Corneal and gag reflexes were preserved. He blinked to visual threat less on the left side, had no clear facial asymmetry, and withdrew on his right arm and knees but had a flaccid left arm. His reflexes were brisker on the left biceps and brachioradialis, and the other deep tendon reflexes were absent. His plantar reflex was upgoing on the left side and downgoing on the right side. CT of the head had no significant findings.

Source: Neurology - August 28, 2017 Category: Neurology Authors: Lin, C.-Y., Yoo, J. Y., Doshi, A., Colman, R. Tags: MRI, Clinical neurology examination, All Cerebrovascular disease/Stroke, Critical care, Video/ EEG use in epilepsy RESIDENT AND FELLOW SECTION Source Type: research