GRAND ROUNDS CASE PROTOCOL

“Ancient Greece’s Inner Chamber”

September 9, 2022 (Friday)

8:00 AM to 10:00 AM
East Avenue Medical Center (Hybrid via Face to Face and Zoom Teleconferencing)

Presenter:
John Christopher V. Ruiz, MD
Year Level II Adult Neurology

Moderator:
Joseph Albert R. Montoya, MD
Year Level IV Adult Neurology
OBJECTIVES:
1. To present a case of a 24-year- old male who came in with Seizure Episodes
2. To review the etiology, anatomy, clinicopathology, radiologic and differential diagnosis of
patients with bilateral thalamic infarct
3. To enumerate the work-up, diagnostics and treatment for patients with Bilateral Thalamic
Infarct
4. To discuss subcortical areas of the brain that may present with seizure

DEMOGRAPHIC DATA:
JA is a 24-year-old, male, right-handed, single, Filipino, Catholic, painter from Quezon City
Metro Manila, who was admitted for the first time in our institution last July 9, 2022.

CHIEF COMPLAINT:
Seizure Episodes

HISTORY OF PRESENT ILLNESS:

(March 2019) 2 Years PTA

Usually after a day’s work patient would experience headache characterized as throbbing and
pulsating in nature, non localizable, non radiating occurring on a monthly basis, lasting for a few
minutes, with no associated vomiting, fever and usually precipitated by work and lots of stress
and relieved spontaneously by rest. Patient did not take any medications nor any consult done.

(July 27, 2022; 8:00 PM) 23 hours PTA

1 Day PTA, while patient was resting and watching Korean Drama, patient experienced sudden
onset headache, generalized, throbbing with a pain scale of 8/10 with associated fever - Tmax
38.2oC. The headache persists and was only relieved partially with intake of medications. Patient
was given Paracetamol 500mg/tab which provided lysis of fever and some relief of the headache
to a pain scale of 1-2/10.
Patient was still able to do activities of daily living like washing plates or cooking food. There
were no associated visual changes, phonophobia, photophobia, cough, colds, ear or eye discharge,
dysuria, fecal incontinence, weakness as well as visual, tactile, gustatory, sensory hallucinations or
loss of consciousness. Still there was persistence of fever, no consult was done.

(July 28, 2022; 06:00 AM) 12 hours PTA

The patient was awakened by his father and was instructed to take medications.
Upon waking up there was still persistence of the headache now with noted increase in severeity
described as the worst headache of his life. There was no associated vomiting, nausea, behavioral
changes, loss of consciousness, visual or tactile hallucinations. Patient went back to sleep after
wards. No consults done and patient had intake of Paracetamol for every 12 hours.

(July 28, 2022; 08:00 AM) 10 hours PTA

Patient was seen by his aunt to have blank stares, assumed to have some visual hallucinations,
with involuntary grasping movement of the fingers and was noted to persist until patient was
brought to the hospital. Patient still responds to name calling by turning his head for a few seconds
however no verbal output noted with associated bruxisms. Patient was still febrile with Tmax
38.4oC. Patient sought online consult from a Family Physician and patient’s relatives were asked
to streak the sides of his right foot, although the results was not stated to them and they were
advised to be brought immediately to the hospital . During this time, there was no associated
Vomiting, Urinary or Fecal Incontinence.

(July 28, 2022; 11:30 AM) 7 hours, 30 minutes PTA

Patient was brought to Capitol Medical Center via a private car and while enroute patient was
noted to have generalized tonic-clonic seizure which lasted for 10 seconds which resolved
spontaneously. Patient was then seen to be drowsy, still non conversant, no associated fecal or
urinary incontinence. Patient was then given unrecalled medications however patient’s relatives
were not allowed to go inside because patient was brought to an isolation room. Patient underwent
MRI and CSF analysis showing stroke and intubation and ICU admission were advised however
due to financial constraints, patient was transferred to our institution.

REVIEW OF SYSTEMS:

GENERAL (-) Easy fatigability, (-) Loss of appetite, (-) Weight loss, (-) Malar
Rash
HEAD AND NECK (-) Nasal congestion, (-) Otalgia, (-) Otorrhea, (-) Neck enlargement,
(-) photosensitivity (-) Carotid Bruits, (-) ear discharge, (-) dental
caries
CHEST AND LUNGS (-) Cough, (+) Difficulty of breathing, (-) Pleurisy
CARDIAC (-) Chest pain, (-) Exertional Dyspnea, (-) Palpitations,
(-) Orthopnea
ENDOCRINE (-) Heat/cold intolerance, (-) Polyuria, Polydipsia, and Polyphagia
GASTROINTESTINAL (-) Abdominal pain, (-) Bleeding, (-) changes in bowel habits
GENITOURINARY (-) Dysuria, (-)Nocturia, (-) Changes in bladder habits
REPRODUCTIVE (-) Abnormal penile discharges/lesions, (-) Bleeding
MUSCULOSKELETAL (-) Joint malalignments, (-) Muscle pains, (-) Arthralgia
PSYCHIATRIC (-) Behavioral changes

PAST MEDICAL HISTORY:

Motor Vehicular Accident (November 11,2021)

- While riding as a passenger on a motorcycle, patient had an accident hitting his head and causing
him to sustain bruises on hands and legs. There was noted loss of consciousness for a brief
moment. There were no consults done.

Appendectomy for Ruptured Appendicitis at St. Vincent Marikina (2018)

Left Achilles Tendon Repair at Capitol (2016)
FAMILY HISTORY:

No history of diabetes, heart problem hypertension, or stroke in the family.

No relative with similar symptoms. No relatives with stroke in the young. No known relative with
autoimmune disorder. No known seizure episodes in the family

PERSONAL AND SOCIAL HISTORY:

High School Graduate at Commonwealth Talanay School (2015)
Vocational studies for Mechanics (2015- present)
Patient took vocational studies for Mechanics at Quezon City. Patient is the eldest and is currently
living with his father, mother and sister. Their house is bungalow type house situated in a
Compound along with 2 houses and is separated from the their neighborhood.

Patient drinks alcoholic beverages 2-3x a week (Hard Drinks , seldomly beer)
Patient is an occasional smoker, 3-4 sticks per day for 3 years only
Patient has a pet dog for about 8 years now
There was no history of exposure to toxic chemicals, doves, or cats and other pets.
Patient denies sexual partners

PHYSICAL EXAMINATION:

Vital Signs: BP – 130/90 mmHg, CR – 86bpm, RR – 24 cpm, Temperature – 36.7 C, Oxygen

Saturation 95% @ 100fio2
Height – 175 cm, Weight – 77kg BMI : 25kg/m2- overweight

Skin: Warm skin, good turgor, no skin lesions, no rashes,

HEENT: Pink conjunctiva, anicteric sclera, supple neck, no lymphadenopathies, no
carotid bruit, non-distended neck veins, otoscopic examination of the ear revealed a pale
tympanic membrane and no discharges
Chest and lungs: Tachypnea, Symmetric chest expansion, fine bibasal crackles,
adynamic precordium, apex beat at 5th ICS MSL, regular rhythm, no murmurs
Abdomen: flat, (+) surgical scar on right lower quadrant, normoactive bowel sound, soft
non tender, no masses, no hepatomegaly or splenomegaly
Extremities: No edema, pulse is full and equal, no clubbing, no cyanosis
Neurologic Physical Examination at ER Level:

Patient was initially seen intubated with spontaneous eye opening, does not follow commands.
Pupils were isocoric, 2-3 mm EBRTL, (+) Visual Threat Intact,
Primary gaze was midline, Full and Equal EOMS via oculocephalic reflex and no gross Facial
Asymmetry noted, (+) Audito-Palpebral Reflex. Patient had spontaneous respiration.
The patient localizes to pain on the bilateral upper extremities and the bilateral lower extremities
withdraws from pain. Patient has +2 reflex on upper and lower extremities.
Extensor toe sign was not elicited on the bilateral plantar area.

Neurologic Physical Examination on 7th Day of Admission

I. MENTAL STATUS EXAMINATION & HIGHER CORTICAL FUNCTION

The patient was mesomorphic, well-kempt, and wore appropriate clothing. The patient was awake
with good attention span. Speech was severely dysarthric. The patient was silent and calm during
the interview and displayed a restricted affect. No signs of agitation but was slow to respond.
Illusions, hallucinations, delusions, and misinterpretations were not observed. Patient had poor
Orientation to date and and place. Patient’s registration is intact. He was able to correctly spell
the word MUNDO forward and backwards. Patient also had poor recall (ano ang hindi nia
marecall). Absence of glabellar tap, palmar grasp reflex, rooting reflex, sucking, or palmomental
reflex responses were observed.

The patient was able to identify watch, pen, and cup correctly. He was able to repeat the phrase,
“Wala ng pa pero pero pa”. He was able to write a complete sentence and copy the figure with
interconnecting lines. He was able to draw the shape of the clock and numbers. He was able to
button his shirt correctly. He was able to say “hinlalaki” when asked to name the right thumb. He
was able to differentiate right and left. He was able to show how to brush his hair correctly. He
was able to tell step by step on how to cook rice. He was able to identify the key was placed on his
palms while his eyes were closed. He was able to identify the single digit, circle and square shape
written on both his palms. He correctly identified on which side the examiner was touching while
his eyes were closed. Patient was having a hard time remembering his birthday. Patient was
also having difficulties remembering the food he ate. Patient was able to identify 3 colors and
has good visual tracking.

II. CRANIAL NERVE EXAMINATION

CN I: Able to distinguish coffee on both nostrils while eyes were closed.

CN II: Visual acuity:20/100 OD 20/70 OS via Pocket Snellen Chart; 20/20, both eyes with use of
corrective glasses. There were no visual field defects on confrontation testing and finger counting.
Fundoscopic findings included presence of red-orange reflex on both eyes. With prominent
vessels and distinct disc margin, present venous pulsation on both eyes. No AV nicking, cotton
wool exudates, or subhyaloid hemorrhages
CN II, III: The pupillary sizes were 3 mm in size, equally round and briskly reactive to light and
accommodation. Patient has intact direct and indirect light reflex.

CN III, IV, VI: Primary gaze was at midline with EOMS full on visual tracking.

CN V: There was 100% sensation equally felt on all V1 to V3 distribution upon touch, pain,
vibratory and temperature stimulation. The masseter and temporalis muscles have good tone.

CN VII: The patient was able to smile with shallowing of the left nasolabial fold. he was able to
distinguish sugar and salt on the anterior 2/3 of the tongue.

CN VIII: There was good gross hearing.

CN IX, X: The gag reflex was intact bilaterally with equal palatal elevation.

CN XI: The patient was able to shrug and he was able to turn her head to sides.

CN XII: The tongue was at midline with no fasciculations or atrophy.

III. MOTOR EXAMINATION

There were no tremors seen on both hands at rest. There were no muscle atrophies and
fasciculations observed. There was good muscle bulk and tone. The motor grade was 5/5 on the
left arm and leg and 5/5 on the right extremities.

IV. REFLEXES

A grade 2 reflex was elicited on right bilateral biceps, triceps, brachioradialis, patellar and
Achilles and grade 3 reflex was elicited on left patellar left brachioradialis. There was no Babinski
reflex.

VI. CEREBELLARS

No scanning speech and nystagmus seen. No truncal ataxia, dysmetria, and dysdiadochokinesia on
both right and left. The patient was able to do heel-to-shin test.

VII. SENSORY

The patient was able to sense light touch, pain, and temperature sensation on all extremities and
was graded 100% equally. There was intact position and vibration sense.

VIII. MENINGEAL SIGNS:

There was nuchal rigidity noted on neck flexion. There were no Brudzinski and Kernig’s signs.
INITIAL WORKING IMPRESSION:
Focal Motor Seizure Unaware evolving to Generalized Tonic Clonic Seizure, Status Epilepticus
probably secondary to 1) CNS Infection 2) Bilateral Thalamic Ischemic Stroke
T/c CNS Infection (Bacterial); Stroke in the Young

COURSE IN THE WARDS:

From the ER Patient was seen to have multiple seizure with versive gazes to the left and evolving
to generalized tonic clonic seizures, also with versive gazes to the right evolving to generalize
tonic clonic seizures. Patient’s vital signs were initially 130/90, 79, 21, 36.1 95%@RA and was
globally aphasic had spontaneous eye opening, isocoric pupils 2mm NRTL preferential gaze to the
right. Versive gaze to the right with noted rapid respiration and bilateral upper extremities
localizes to pain. There was no noted babinski or Nuchal Rigidity.
Patient was diagnosed with Focal Motor Seizure probably Status Epilepticus secondary to CNS
Infection ; T/c CNS Infection Probably Bacterial; Acute Respiratory Failure Type 2 Unaware
secondary to Decreased CNS Drive probably secondary to Post Infectious Cause. Patient was
scheduled for CSF Analysis, Blood CS x 2 sites, ABG, 21L - EEG, retrieval of Cranial MRI with
Contrast, Procalcitonin, CBC and Electrolytes.
Patient had seizure episodes every 5 minute despite the doses of Diazepam and Levetiracetam.
Patient was then started on Midazolam Drip hooked to Plain NSS at 100cc/hour. Ancillary
procedures were done. Patient was given Ceftriaxone 2g/IV Q12, Dexamethasone 10mg/ IV Q6
for 4 days, Levetiracetam 500mg in 90 cc PNSS to run for 45 mins Q12, Vancomycin 2g/ IV in
PNSS to make 100cc to run for 1-2 hours via infusion pump every 12 hours, Enoxaparin 0.6cc SQ
OD, Atorvastatin 40mg/tab ODHS, Citicholine 1g/IV Q12, Omeprazole 40mg IV OD preBF.
Patient was hooked to a Mechanical Ventilator immediately. Patient was then hooked immediately
transferred to ICU

On the 2nd Day, 1st Day of ICU patient had no eye opening to pain, pupils 3mm SRL, isocoric,
roving eyeballs, primary gaze midline, (+) Doll’s eyes, nuchal rigidity was questionable. Patient
underwent lumbar puncture.

On the 3rd hospital day, there was no recurrence of seizure, fever or desaturations, unremarkable
general P.E, pupils 2mm isocoric primary gaze midline, (+) Doll’s eyes, Spontaneous respiration,
spontaneous movement on all extremities. During the course in the wards patients self- extubated
and was able to tolerate oxygen supplementation with face mask

On the 4th to 5th hospital day, patient had no recurrence of headache, seizure or decrease in
sensorium. Patient was awake, nods to questions, follows commands, 3mm isocoric reactive to
light, primary gaze was midline, full and equal EOMS, no facial asymmetry, spontaneous
movement of extremities. Atorvastatin was withheld and Mannitol infusion was tapered.

On the 6th - 11th day of admission still patient was being treated for the infection
On the 12th- 14th day of admission, antibiotics were withheld. Patient was then diagnosed as a case
of Bilateral Thalamic Infarct probably secondary to 1) CNS Infection probably Viral 2) Cerebral
Venous Thrombosis and was sent home with Dabigatran 150mg/tab BID, Levetiracetam
500mg/tab BID, Atorvastatin 40mg/tab ODHS with request for CSF Neurosyphylis Test.

FINAL DIAGNOSIS:
Focal Motor Seizure Unaware evolving to Generalized Tonic Clonic Seizure probably secondary
to Bilateral Thalamic Infarct from 1) CNS Infection probably Viral 2) Cerebral Venus Sinus
Thrombosis; Stroke in The Young

LABORATORY AND DIAGNOSTIC WORK UP:

CBC with Platelet

Date WBC Hgb Hct Neu Lymp Mono Eos Baso Plt BT
7/28/2022 143 44 211
(From Capitol
7/28/2022 9 142 42 89 8 3 0 0 211 B+
7/30/2022 8 137 41 83 13 4 0 0 171
8/2/2022 19 120 35 96 3 1 0 0 188

Blood Chemistry
Date Crea BUN Na K Cl Ca Mg Phos AST ALT RBS
7/28/2022 68 3.6 135 4.1 1.23 .75
7/28/2022 73.8 3.4 133.7 3.69 98.2 31 27 134.91
7/30/2022 69.8 3.8 135.8 3.07 98.7 1.09 0.83 0.82 123 49 160
8/2/2022 75.6 3.9 144 3.68 99.9 1.33 131 135 140

Blood CS x 2 Sites
7/31/2022
No Growth after 5 days of Incubation

Urinalysis
Color Transparency pH RBC WBC Epi Mucus Bact Prot Blood

7/29/2022 Yellow Sl. Cloudy 6 4-6 3-5 Few Occasional Few (-) (-)
8/3/2022 Yellow Cloudy 6 50-60 2-4 Few Few Few (-) (-)

Blood Chemistry
Date Procalcitonin LDH
7/30/2022 372
7/31/2022 < 0.10
Coagulation Factors
Date PT Control INR %act PTT Control
7/28/2022 15 12.2 1.21 58.5% 41s 31.5

ABG
Date pH PCO2 PO2 HCO3 Fio2
7/28/2022 7.344 47.1 37 24 21
7/30/2022 7.430 39 339 25.9 80
7/31/2022 7.466 42.1 99 29.7 40

CSF Studies 7/30/2022

Colorless, slightly turbid, Approximately 1.5ml
Gram Stain: None
Culture: No Growth after 3 Days of Incubation
CSF Studies Protein Sugar CSF- Opening Closing
Serum Pressure Pressure
Sugar
Ratio
7/30/2022 124.8 90.09 0.56 14cmH20 15cmH20
mg/dl mg/dl

CSF Test
VDRL (-) non reactive
Dengue IgG (+)
Dengue IgM (-)
Herpes HSV I IgG (-)
Herpes HSV II IgG (-)

Red Blood Cells 21 x 106/L Differential Count:

White Blood Cells 7 x 10 /L
8 Neurophils 20%
Lymphocytes 80%
Total Cell Count 28 X 108/L Total 100%

Chest X-ray
7/28/2022 EXAMINATION: CHEST AP SITTING
Radiographic findings:
Previous study done on 07/28/2022 was reviewed.
Present study shows no significant interval change in the previously noted pneumonic
infiltrates in both lungs. Underlying pulmonary congestive process cannot be totally
ruled out. The rest of the findings remain unchanged.
Non Enhanced Cranial CT Scan
7/28/2022 PERTINENT HISTORY: FEVER, SEIZURE EPISODE; POSITIVEKERNIG AND
BRUDZINSKI SIGNS
PLAIN CT SCAN OF THE HEAD
Multiple contiguous axial images of the head were obtained without intravenous
contrast.
There are no abnormal density changes in the brain parenchyma. The parenchymal
gray-white interface is normal. The ventricles, cisterns and sulci are normal in size
and shape. There is no midline shift or mass effect. The mastoid air cells and
visualized paranasal sinuses are well aerated. The visualized osseous structures are
unremarkable. NGT is noted.
IMPRESSION:
Unremarkable CT scan of the brain.
Follow-up study with contrast-enhanced cranial CT scan or MRI is suggested if
clinically warranted.
Contrast Enhanced Cranial CT Scan
7/30/2022 PERTINENT HISTORY: FEVER, SEIZURE EPISODE; POSITIVEKERNIG AND
BRUDZINSKI SIGNS
CONTRAST ENHANCED CT SCAN OF THE HEAD
Multiple contiguous axial images of the head were obtained with intravenous
contrast.
Previous study done on July 28, 2022, was reviewed.
Present study still shows no abnormal density changes in the brain parenchyma. The
parenchymal gray-white matter interface is normal.
No leptomeningeal enhancement nor enhancing mass noted after contrast
administration. No aneurysmal dilatation, extraluminal contrast extravasation
nor filling defect noted in the intracranial vessels.
There is no midline shift, mass or mass effect. The ventricles, cisterns and sulci are
normal in size and shape.
There is now minimal mucosal thickening in both ethmoid sinuses. Likewise, partial
pacification is now noted in both sphenoid sinuses and both
mastoid air cells.
Other paranasal sinuses are well aerated. The visualized osseous structures are
unremarkable.
Nasogastric tube is still seen. An endotracheal tube is now seen in place.
IMPRESSION:
Unremarkable contrast-enhanced CT scan of the head.
Polysinusitis.
Mastoiditis, bilateral.
Cranial MRI with MRA and MRV with Contrast (iScan)
8/6//2022 There are fairly symmetrical and fairly defined small (about 1 cm) nodular T2/FLAIR
hyperintense abnormal signals with restricted diffusion in the superior paramedian
aspect of the bilateral thalami. T1 hyperintensities and SWI blooming are seen
suggestive of blood product/hemorrhage. There is apparent enhancement in the
post-Gd study.
Gray-white matter differentiation is preserved. The cisterns and sulci are not effaced.
The ventricles are within normal limits. Midline structures are in place.
The sella/suprasellar, pineal, cavernous sinuses, cerebello-pontine angles, brainstem
and cerebellum show no discrete abnormality.
No abnormal meningeal enhancement.
The Circle of Willis is well demonstrated. No ectatic segments or foci of aneurysm
are detected. There are no tangle of vessels to suggest arteriovenous malformation.
Both internal carotid arteries show no area of stenosis. The
included segments of both vertebral arteries and basilar artery are likewise normal in
caliber. The dural sinuses are patent on MRV.
There is mild mucosal thickening in some of the paranasal sinuses.
IMPRESSION:
• Fairly symmetrical small nodular T2/FLAIR hyperintense abnormal signals with
restricted diffusion in the
superior paramedian aspect of the bilateral thalami with T1 hyperintensities and SWI
blooming suggestive of
blood product. Differentials include vascular insult/infarction, metabolic/toxic
disorder or infectious encephalitis
Unremarkable MRA and MRV
Mild polysinus disease

OPS/NPS RTPCR TEST FOR COVID 19

7/12/2022 Negative