Correct!
5. All of the above
Clearly there has been a change resulting in a decline in his mental status. A repeat of the electrolytes, arterial blood gases and the other laboratory values revealed no real change compared to the previous days when he was improving. A repeat head CT scan followed by an MRI showed an acute cortical infarct involving the right parietal, occipital, and posterior temporal lobes (Figure 1).
Figure 1. Panel A: Head CT after reintubation and second hypertensive crisis shows an acute cortical infarct involving portions of the right parietal, occipital, and posterior temporal lobes with potential anterior right temporal lobe involvement suggestive of a watershed infarction (arrow). Panel B: Brain MRI confirms the acute cortical infarct in addition to right aspect of pons and left basal ganglia (arrow).
Given the multiple scattered vascular ischemic events in a bilateral distribution and in unusual locations, this presentation would normally be considered embolic in terminal vessel territories. However, the patient did not have any typical vascular embolic phenomena including atrial fibrillation or left ventricular thrombus with a normal TTE. After careful consideration, this case was favored to represent severe ethylene glycol toxicity causing microscopic calcium oxalate crystal emboli (5).
The patient remained on supportive treatment for multiple days, but ultimately improved sufficiently to be transferred to Inpatient Behavioral Health for further treatment of his probable suicide attempt. At the time of transfer, he had residual confusion, memory loss and right full body weakness and atrophy.
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