Disclosures: Michael D. Harbus, DO: Nothing to disclose

Case Description: A 77-year-old male presented to the emergency room following a syncopal episode that resulted in him hitting his head on a table. The patient has a medical history significant for hypertension, hyperlipidemia, diabetes, three myocardial infarctions requiring a coronary artery bypass graft and stents, and an ejection fraction of 25%. In the emergency room, the patient’s CT head showed a left subdural hematoma with 5-mm rightward midline shift. The patient underwent a craniotomy with subdural evacuation and was transferred to the acute inpatient rehabilitation unit after medical stabilization. On the rehabilitation unit, the patient had multiple episodes in therapy during which he would become disoriented, and severely dysarthric, which was believed to be related to seizures.

Setting: Acute Inpatient Rehabilitation Uni.t

Patient: 77-year-old male with congestive heart failure.

Assessment/Results: A video EEG was ordered which captured an episode of disorientation and dysarthria. On the EEG, this episode correlated with global attenuation suggesting hypoperfusion to the brain. A CT angiogram of the head and neck was performed which showed no large vessel occlusion, or high-grade stenosis. Orthostatic testing was positive. Medicine was consulted and the patient’s orthostatic hypotension was attributed to diabetes-induced autonomic dysfunction in the setting of heart failure.

Discussion: This is a case in which transient episodes of disorientation and dysarthria were initially attributed to seizures, but further workup revealed the episodes were in fact due to hypoperfusion. Of note, the patient began having these episodes when participating in therapy when he was either seated, standing, or ambulating, and when blood flow was increased to peripheral muscles, likely leading to cerebral hypoperfusion.

Conclusion: This case shows the necessity of implementing strict precautions, and frequent blood pressure monitoring during therapy for patients with diabetes and a complex cardiac history.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/dysautonomia-masquerading-as-seizures-a-case-of-disorientation-and-dysarthria-in-a-patient-with-a-subdural-hematoma-diabetes-and-an-extensive-cardiac-history/