Hypoxic ischemic brain injury with status myoclonus in a case with post-operative massive pulmonary thromboembolism: A diagnostic and therapeutic challenge

Abstract

Thromboembolic event is an important and widely regarded risk factor, influencing the outcome and overall survival in post-operative cases with second highest association with gynaecological surgeries. Here we report a 52 years old female who underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH+BSO) presented to our emergency in unconscious and intubated state on her post-operative day-1 with cardiorespiratory failure. Based on the immediate investigations after successful resuscitation, an initial diagnosis of massive pulmonary thromboembolism was made following supportive and conservative management. Interestingly on subsequent days she started to display episodic non-rhythmic symmetric myoclonic jerks persisting for seconds to minutes; resembling ‘post-hypoxic’ or ‘post-anoxic’ status myoclonus due to hypoxic ischemic brain injury. Further neuro-electrophysiological examination revealed rhythmic well-formed delta activity on both sides symmetrically with a transformation into theta activity with forward displacement on subsequent days, bilaterally over the same areas. Later on, magnetic resonance imaging with magnetic resonance-spectroscopic findings also corroborated to hypoxic ischemic brain injury related changes over bilateral basal ganglia mostly in caudate nucleus. Post operative venous thromboembolism is a major clinical challenge and a subject of constant intensive care yet the neurological sequalae of such event is given less priority despite of its major contribution on overall prognostic and survival index.