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An unusual cause of stroke and hypoxia

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c7200 (Published 27 April 2011) Cite this as: BMJ 2011;342:c7200
  1. Sarah Louise Bell, foundation year one doctor,
  2. David J Eveson, consultant physician in stroke medicine
  1. 1Department of Stroke Medicine, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
  1. Correspondence to: D J Eveson david.eveson{at}uhl-tr.nhs.uk

A 70 year old retired farmer was referred by his general practitioner to the medical assessment unit for a sudden onset of “dizziness.” Since the episode that morning, he had been unable to walk steadily, had a tendency to veer to the left side, and had a mild feeling of rotation. He had no history of headache, deafness, or tinnitus; his symptoms did not vary with posture; and he had not noticed any visual disturbances. He had no cardiorespiratory symptoms.

His medical history included a right sided frontoparietal cerebral infarct the previous year, from which he had made a full recovery. At that time, he was prescribed aspirin, modified release dipyridamole, and simvastatin. A cerebral abscess had been diagnosed during his 40s, for which he had received a prolonged course of intramuscular antibiotics. He had also undergone multiple cauterisations since his teenage years for recurrent nosebleeds and surgical treatment for varicose veins.

His son died of a cerebral haemorrhage of unknown type at the age of 17. His only other child, a daughter aged 46, was fit and well. He was a lifelong non-smoker and drank alcohol within recommended limits.

Observations revealed a regular pulse of 70 beats/minute, blood pressure of 118/73 mm Hg, temperature of 36.0 °C, respiratory rate of 18 breaths/min, and oxygen saturation of 81% on room air. He was noted to have central and peripheral cyanosis, clubbing of the digits, and perioral telangiectasia. Heart and chest auscultation were normal. Neurological examination showed mild dysarthria with cerebellar ataxia, including a left sided intention tremor on finger-nose testing, left sided dysdiadochokinesis, and a positive heel-shin test.

Arterial blood gas on room air showed a PaO2 of 7.5 kPa, PaCO2 of 4.1 kPa, pH of 7.46, HCO3 of 23.6, and base excess of −1.6. Haemoglobin concentration …

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