Physician, Fellowship director Henry Ford Hospital
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Introduction: Brainstem seizures are a rare phenomenon of brainstem stroke possibly resulting from injury to the proposed centrencephalic system. We observed hypoxic respiratory arrest resulting from these brainstem seizures involving tonic spasm of the diaphragm, a complication to our knowledge not previously reported in the literature.
Description: A 69-year-old female presented with acute onset of altered mental status and left-sided weakness. CT angiography showed basilar artery thrombosis. The patient was taken for a thrombectomy, but recanalization could not be achieved. An MRI of the brain demonstrated acute infarction of the pons and bilateral cerebellum. Several days later, she had a sudden episode of acute hypoxia with oxygen saturation dropping to as low as 30. On evaluation, the patient appeared to have tonic spasms of her respiratory muscles resulting in complete respiratory arrest with loss of tidal volume, refractory hypoxemia, hemodynamic instability, and limited chest wall movement with manual ventilation. She required increased sedation which allowed the team to effectively ventilate her along with improvement in her hemodynamics and oxygen saturation. She developed another tonic spasm which was refractory to additional doses of sedation. Cisatracurium was administered which aborted this phenomenon resulting in a rapid clinical improvement. The patient continued on high doses of sedation and was started on carbamazepine as daily preventative therapy. After this treatment strategy was initiated, the patient was not observed to have any further episodes.
Discussion: Brainstem seizures with diaphragmatic tonic spasm represent a rare complication of basilar artery occlusion. This phenomenon is not well described in literature making it difficult to manage, ultimately leading to high-risk clinical scenarios such as hypoxic respiratory arrest. Our case highlights a dual pronged approach to management including abortive therapy, utilizing high doses of sedation and neuromuscular blockade, in conjunction with a preventative strategy with an antiepileptic drug, carbamazepine. Further studies are required to identify the underlying etiology of diaphragmatic tonic spasms and treatment guidelines in order to prevent patient harm.
