1. AN INTERESTING CASE OF ACUTE QUADRIPARESIS VII MU PROF.DR.M.MUTHIAH, M.D DR.D.GANESAPANDIAN,M.D DR.G.GURUNAMASIVAYAM,M.D

2. History.. 55 year old male patient Mr.Ramu, admitted with complaints of.. –Sudden onset of giddiness and swaying followed by –Loss of consciousness for 1 hour –Weakness of all 4 limbs 5 hours

3. Apparently normal till 5 hours ago Sudden onset of giddiness and swaying to left side Pt had Loss of consciousness for nearly 1 hour and on regaining consciousness found that he was unable to use any of his limbs Pt fully conscious on admission to GRH

4. H/O inability to move all 4 limbs. –Simultaneous involvement of all 4 limbs –Weakness more in upper limbs than lower limbs –static weakness No H/O fasciculations/twitching No H/O involuntary movements H/O decreased sensation below the neck(onset along with the weakness) No H/O root pain H/O retention of urine+ H/O constipation+

5. No H/S/O cranial nerve involvement No visual disturbances No disturbances of facial sensation No seizures/ speech or memory disturbances no H/O fever

6. No H/O chest pain No H/O cough/ expectoration No H/O prior recurrent syncopal attacks/ palpitations

7. Past history No H/O similar episodes in the past Not a known pt of DM/HT/BA/PT/IHD/ seizures No past H/O TIA No H/O major hospitalisation in the past

8. Personal history Takes mixed diet Manual labourer by ocupation Not a known smoker or alcoholic

9. On examination Elderly male Moderately built and nourished Conscious and oriented Comfortable at rest No pallor/icterus/clubbing/cyanosis/ pedal edema/lymphadenopathy No rash

10. Vital data PR: 86/min, regular, normal volume. Felt in all palpable vessels, both carotids equal BP: 130/80 mmHg in RUL RR: 16/min Temp: normal

11. Examination of nervous system Higher mental function: normal, right handed individual Cranial nerves: normal Pupils: 3mm reacting to light equally on both sides Gaze evoked nystagmus present bilaterally more to left side Facial sensation normal Fundus: normal

12. Spinomotor system.. Day 1 RightLeft ULLLULLL BulkNNNN Tone decreased Power shoulder0/5 elbow0/5 wrist0/5 hip1/5 knee1/5 ankle1/5

13. Reflexes.. day1 CornealPresentpresent abdominalAbsent absent PlantarNo response BicepsAbsent TricepsAbsent SupinatorAbsentabsent KneeAbsent AnkleAbsentabsent

14. Spinomotor system.. day4 RightLeft ULLLULLL BulkNNNN Tone Increased increased Power shoulder2/5 elbow2/5 wrist3/5 hip3/5 knee3/5 ankle3/5

15. Reflexes.. day4 CornealPresentpresent abdominalAbsent absent PlantarExtensor Biceps++ Triceps++ Supinator++ Knee+++ Ankle++

16. Sensory system… Rightleft Fine touchImpaired PainAbsent TemperatureAbsentabsent VibrationNN Joint positionNN Cortical sensation normal All sensory disturbances below C5 level

17. No involuntary movements No fasciculations Coordination: could not be tested Cerebellar functions: could not be tested Gait: could not be tested No meningeal signs Spine and cranium normal Height neck ratio normal

18. Others systems Clinically normal

19. Provisional diagnosis… Acute onset spastic quadriparesis with initial spinal shock and involving pyramidal tract, anterior spinothalamic tract, sparing the dorsal column( sensory dissociation). Bladder involvement+ motor level between C3 and C5, reflex level above C5 and sensory level C5. Spinal vibration normal

20. Neurologist’s opinion ? Central cord syndrome To R/O posterior circulation stroke Suggested MRI brain

21. Investigations.. Hb: 12.4gm% TC: 6700 cells/cu.mm DC:P58L40E2 ESR: 16mm/hr Peripheral smear: normal study Urinalysis: –Albumin: nil –Sugar: +++ –Deposits: nil –24 hour urine protein excretion: 50mg/day

22. Blood urea: 32mg% S.creatinine: 0.8mg% Blood sugar: –Admission: 345mg% –FBS: 234mg% –PPBS: 300mg% T.cholesterol:289mg% LDL: 210mg% VLDL: 34mg% HDL: 40mg% TGL: 265mg%

23. Serum electrolytes Day1 –Na: 138meq/L –K: 4.0meq/L –Cl: 100meq/L –HCO3: 20meq/L Day4 –Na: 140meq/L –K: 4.2meq/L –Cl: 98meq/L –HCO3: 2meq/L

24. Others.. ECG: sinus rhythm, normal axis, normal study ECHO: normal study USG abdomen: normal study CT brain: no significant abnormality Ophthalmologist’s opinion: no evidence of diabetic retinopathy, no visual deficit

25. MRI brain and spine…

29. MRI spine… Mild diffuse enlargement of cervical cord with intramedullary bright signal extending from C2 to T1 with minimal skip areas Lesion predominantly located at central and anterior aspect of spinal cord Bony structures normal Bright signal replacing the normal flow void of left vertebral artery( S/O left vertebral artery occlusion) double lumen seen with intimal flap.. ?vertebral artery dissection with luminal thrombus Above findings suggestive of spinal cord infarction

34. MRI brain… FLAIR bright signal lesion with diffuse restriction involving left cerebellum(vermis, anterolateral cerebellar hemisphere, middle and inferior cerebellar peduncle) with effacement of fourth ventricle with CPA cisterns.. Representing acute infarct( AICA and SCA territories) Multiple chronic infarcts involving both corona radiata and centrum semiovale, biparietal, subcortical and periventricular regions)

35. Final diagnosis.. Type 2 diabetes mellitus with dyslipidemia Acute spastic quadriparesis Sensory involvement with sensory dissociation Spinal shock recovered As a consequence of spinal cord infarction due to ?vertebral artery thrombosis, ?vertebral artery dissection

36. Course of illness.. Pt treated with insulin, aspirin, clopidogrel and statins Bladder was catheterised Limb physiotherapy was given Muscle power improved well Pt was discharged after 1 week and went home walking Catheter removed

37. THANK YOU