-A 85 year old male Known hypertensive for 20 years on amlodipine 10 mg,end stage renal disease for 6 months on regular haemodialysis, presented with high grade continuous fever associated with rigor, confusion and decrease level of consciousness for 2 days; at the same times his family noticed that he was unable to speak, swallow or to move his limbs there was no mouth deviation or history of seizure.
-On examination: the patient looked unwell with NG tube and permeant haemodialysis catheter, pulse 80,BP 160/100, cardiovascular system revealed tender hepatomegaly with bilateral lower limb oedema; neurological examination:GCS6/15 (Aphasic+spontinous eye opening),Bilateral cataract, no neck stiffness or carotid bruit, right side showed hypotonia with normal reflexes, left side findings include hypotonia and hyper reflexia with extensor planter reflex. Power, sensation and coordination couldn’t be assessed (locked in syndrome), fundoscopy not done.
-Investigations shows: Twbcs 17, Haemoglobin 6.5 (normocytic normochromic), Platelets 131, RBG 184,RFT:urea142 mg/dl,S.creatinine 7.2 mg/dl,Na 122mmol/l,K5 mmol/l, INR 1.7. MRI brain, MRA & MRV confirm a diagnosis of top of basilar artery infarction.
-the patient received i.v antibiotics renal dose, dual antiplatelet therapy, enoxaparin 4,000 i.u O.D, blood transfusion, and frequent session of haemodialysis. Later the patient developed bilateral epistaxis and bleeding per mouth manged with fresh frozen plasma, heparin free haemodialysis session and stopping of enoxaparin and antiplatelets. Patient discharged 14 days later static on locked in with GCS 6/15.