Resident Physician Johnson Rehabilitation Institute at JFK Medical Center New Brunswick, New Jersey, United States
Case Diagnosis: Acute ischemic stroke in the right centrum semiovale
Case Description: An 86 year old male presented to the Emergency Department for 1 day of hematemesis. He was found to be in hemorrhagic shock and he required 3 units of packed red blood cells, intubation, and vasopressors. Following sedation weaning and extubation, his mental status continued to progressively decline. MRI brain revealed acute infarct in the right centrum semiovale. It was suspected that a hypoxic-ischemic brain injury occurred due to hypovolemia at the time of hospital presentation in the setting of massive hematemesis. Once medically stabilized and with improvement in mental status, he was discharged to acute inpatient rehabilitation for targeted therapy of activities of daily living and cognitive dysfunction secondary to acute ischemic stroke.
Discussions: Hypovolemic shock is known to cause ischemic brain injury due to hypoperfusion, especially in watershed zones. These zones with narrowed arteries are vulnerable to slight changes in perfusion, and are at high risk for damage resulting from significant hypovolemia. In severe cases, lack of adequate perfusion results in tissue hypoxia, which could lead to organ dysfunction and subsequent multiorgan failure if left untreated. In the case of this patient, it is thought that the acute blood loss and hypovolemia resulting from massive hematemesis directly caused his ischemic brain injury.
Conclusions: If hypovolemia is severe enough to cause hemodynamic instability and collateral blood supply within the brain is not sufficient, watershed zones are at risk for compromise and brain injury may occur.
