LAUSR

Case Presentation An 81-year-old right-handed female with a past medical history significant for coronary artery disease, hypertension, and paroxysmal supraventricular tachycardia presented initially to the emergency room after falling at home. The patient denied any prodromal symptoms preceding the fall. She denied loss of consciousness and was uncertain if there was an impact to the head. At presentation, she was alert and did not have any neurological deficits. Her blood pressure was 126/91 and heart rate was 100. A peripheral intravenous catheter was inserted, and she was started on a normal saline bolus. Her son recalls that she was in the sitting position during the time of intravenous access placement. Within a minute of line insertion and fluid initiation, she suddenly developed a blank stare with head version to the left. This was followed by tonic elevation and flexion of her right arm above her head with outward extension of the left arm. Symptoms lasted for 2 to 3 minutes, followed by a prolonged period of confusion. Because of concern for seizure, she was given 2 mg of lorazepam and loaded with 1500 mg of levetiracetam. Shortly after, she developed hypoxic respiratory failure and subsequently required intubation. An emergent noncontrasted head computed tomography was performed, which showed air in the right parieto-occipital sulci, as well as the Sylvian fissure (Figure 1A and 1B). The calvarium was intact without fractures. She was transferred to our tertiary hospital for further care. ECG at time of transfer did not show concerning changes. Repeat head computed tomography performed 5 hours after the initial seizure demonstrated sulcal effacement and resolution of air emboli in the right parieto-occipital region (Figure 1C and 1D). Another head computed tomography 18 hours later showed hypodensities in the right occipital and temporal lobes. Magnetic resonance imaging of the brain confirmed acute infarction (Figure 2). Magnetic resonance angiography did not show intracranial atherosclerosis or significant stenosis in the carotid or vertebrobasilar system. Video electroencephalogram showed right parieto-temporal status epilepticus, and levetiracetam was increased from 500 mg twice daily to 1000 mg twice daily. Her transthoracic echocardiogram the next day showed a mild elevation in right ventricular systolic pressure. It did not demonstrate an intracardiac shunt. However, a prior transthoracic echocardiogram report suggested the presence of a small patent foramen ovale. She clinically improved over the course of a week once her seizures were controlled. Her respiratory status stabilized and she was extubated after a few days. At the time of discharge to an acute rehabilitation facility, she had residual left homonymous hemianopsia and mild left upper extremity weakness. The deficits persisted when re-examined 2 months after discharge.