Title : A vascular catastrophe: A case of a 72-year-old Filipino male who developed ACS-STEMI after hemorrhagic conversion of an ischemic stroke
Abstract:
The patient is R.M., 72-year-old, Filipino male, who came in with a chief complaint of dizziness. Four hours prior to admission, he was walking home when he noted sudden onset non-rotatory dizziness with no associated nausea, vomiting, loss of consciousness, headaches or body weakness. Persistence of symptoms prompted consultation and admission.
He was received at the emergency room with symptoms of non-rotatory dizziness, but no other subjective complaints. His blood pressure was elevated at 160/90, with noted irregularly irregular cardiac rhythm on auscultation, as well as focal neurological deficits. Due to persistence of symptoms and for closer monitoring for deterioration of neurological status, patient was referred to Neurology service, admitted to the ICU, and started on
Aspirin, Atorvastatin, Betahistine, Citicoline, Omeprazole, and Enoxaparin. Further workup was done including 2D Echo with Doppler Studies, Carotid Duplex Scans, and AV Duplex Scans of the bilateral lower extremities.
The next day, the patient underwent Cranial MRI with MRA under the advice of Neurology service due to persistence of dizziness and episodes of hypertension. The patient also waived ICU management due to financial constraints, hence he was transferred to the wards. Upon facilitation of cranial MRI, there was noted hemorrhagic conversion of initial infarctions, hence Aspirin and Enoxaparin were discontinued, and he was started on Mannitol and Telmisartan.
During the next hospital days, his neurological status remained stable with no new deficits, and he was referred to Rehabilitation service for physical therapy. Therapy initially began with bed repositioning and sitting, and progressed to bedside exercises and rising from bed.
On the patient’s 12th hospital day, he was cleared for discharge from all services, however after less than 5 minutes of routine physical therapy session, he experienced sudden onset dyspnea with diaphoresis. The patient was hypotensive at 50/30, with other vital signs stable. He was placed on complete bed rest, hooked to oxygen support at 6 LPM nasal cannula, and repeat laboratories were requested. Due to no resolution of hypotension after
fast drip of a total of 300cc pNSS, patient was started on both Dobutamine and Norepinephrine drips. Laboratories revealed a septal wall infarction on ECG and elevated Troponin I, hence the patient was treated as a case of ACS-STEMI. After conferring with Neurology service, he was started on Aspirin, Clopidogrel, Enoxaparin, and Trimetazidine, and transferred back to the ICU.
The patient was referred to Pulmonology service for co-management, and a diagnosis of pulmonary embolism was also considered, hence the patient was advised CT Pulmonary Angiography once more stable. At the ICU, the patient's inotropes were titrated accordingly and tapered as the patient's blood pressure stabilized. On his 15th hospital day, patient again waived ICU management and CT Pulmonary Angiography due to financial constraints,
and transferred to the wards. Over the next days, there was no noted recurrence of dyspnea, hypotensive episodes, or new neurologic deficits. Medical management was continued, and on the patient’s 20th hospital day, he was deemed fit for discharge from all services and sent home well.
