Stroke
Lisa Y. Gong, MA
Medical Student
Georgetown University School of Medicine
Cookeville, Tennessee, United States
Haidy Beshay, MD
Resident Physician
MedStar Georgetown University Hospital, Department of Neurology
Washington, District of Columbia, United States
Oluwaseyi Olulana, MD, MS
Resident Physician
MedStar Georgetown University Hospital, Department of Neurology
Washington, District of Columbia, United States
Mary C. Denny, MD, MPH
Attending Physician, Assistant Professor of Neurology, Co-Vice Chairman of Operations
Georgetown University School of Medicine, MedStar Georgetown University Hospital, Department of Neurology
Washington, District of Columbia, United States
Lisa Y. Gong, MA
Georgetown University School of Medicine
Cookeville, Tennessee, United States
Exertional heat stroke leading to multiorgan dysfunction, acute liver failure (ALF) requiring emergent orthotopic liver transplantation (OLT), acute kidney failure (AKF), multifocal ischemic strokes (bilateral thalamic, left cerebellar), right parietal intracerebral hemorrhage (ICH), all secondary to distributive shock and disseminated intravascular coagulation (DIC).
Case Description:
A previously healthy 26-year-old male National Guardsman collapsed following a 5-mile training run while carrying a 60-pound backpack in 70°F weather and was diagnosed with exertional heat stroke. Mental status deteriorated quickly with rapid development of multiorgan dysfunction, including ALF, AKF, DIC, and distributive shock, requiring transfer to a quaternary care hospital for emergent OLT.
Initial CT head was normal, but CT head and MRI after transfer and intubation for respiratory failure revealed right parietal ICH and bilateral thalamic and left cerebellar hypodensities consistent with subacute ischemic strokes secondary to cerebral hypoperfusion. Following prolonged mechanical ventilation (11 days, 2 intubations), the patient demonstrated weakness (2/5 proximal BUEs, 4+/5 distal BUEs, 4/5 proximal LLE, 3/5 distal LLE, 4/5 RLE), left-sided dysmetria, dysphagia, and cognitive impairment (executive function, attention). Prompt PT, OT, and SLP intervention facilitated early improvement of functional deficits and timely transition to acute inpatient neurorehabilitation.
Discussions: DIC and distributive shock are severe complications of exertional heat stroke, predisposing this patient to ischemic and hemorrhagic strokes. Bilateral thalamic strokes resulted in proximal weakness and cognitive deficits, while cerebellar involvement led to impaired coordination. Neurorehabilitation efforts were further complicated by multiorgan failure and liver transplantation, requiring immunosuppression with concern for infection and acute rejection. Nonetheless, early rehabilitation proved crucial for functional recovery, addressing motor weakness, dysphagia, and cognitive impairment.
Conclusions:
Exertional heat stroke may be associated with risks of stroke and multiorgan failure requiring transplantation. Early assessment and coordination of multidisciplinary rehabilitation from the acute phase through discharge to rehabilitation facilities are critical to minimize long-term disability and neurological sequelae.
