733 - Unusual Cognitive Presentation of Adult Male Post Hypoxic Brain Injury

Case Diagnosis: The patient is a 61-year-old gentleman with hypertension, morbid obesity, hypothyroidism, OSA, and no previous stroke who came to post-acute rehabilitation after a myocardial infarction (MI) resulting in hypoxic ischemic encephalopathy (HIE). Resulting deficits included apraxia, aphasia, right hemiparesis, and cognitive impairment.

Case Description: The patient was found unresponsive at home by family. After 5-6 minutes of CPR with 2 defibrillations, return of spontaneous circulation was achieved. The EKG showed a STEMI and he received a cardiac stent for LAD occlusion. Imaging showed subtle brain parenchyma hypoattenuation and loss of gray-white differentiation reflecting HIE. The patient’s main cognitive impairments included attention and orientation. Aphasia manifested as deficits in word finding and language comprehension. Apraxia was demonstrated by inability to appropriately use silverware. In rehabilitation, he had good carry-over between physical therapy sessions. Confabulations, which often occur after hypoxic brain injury, were not present.

Discussions: Hypoxic injury occurs when the brain’s oxygen requirement is not met. Common causes include cardiac arrest, near-drowning, and drug overdose. The immediate and post-acute sequelae are varied with patient presentations ranging from mild impairments to coma state. Opposed to a global cognitive deficit commonly seen in hypoxic brain injury after cardiac arrest, this patient had more focal deficits resembling that of stroke. One possible explanation for his unusual presentation is the rapid initiation of quality CPR by family members until EMS arrived. Compressions at the appropriate rate and depth may have prevented global ischemia in the brain. He made significant progress in rehabilitation over a few weeks, particularly in language comprehension.

Conclusions: This patient exhibits a unique presentation of a HIE injury that resembled focal deficits seen in stroke patients. Additionally, he improved rapidly in the post-acute setting. This case demonstrates the potential downstream effects of high-quality CPR in patients beyond the critical state and into rehabilitation for survivors.