Here - American Geriatrics Society

P OSTER
A BSTRACTS
episode. He was alert and coherent but noted to be diaphoretic,
tachycardic and hypotensive with an irregular pulse. EKG revealed
supraventricular tachycardia which converted to sinus tachycardia
with IV adenosine. His hypotension remained refractory to normal
saline boluses and a norepinephrine infusion was added with resultant
blood pressure stabilization. Initial laboratory evaluation revealed
normal electrolytes, hematocrit of 40%, WBC 14.8 x 10^9 /L,
Troponin I 0.10ng/ml and INR 1.4. A repeat EKG showed atrial fibrillation
with diffuse ST depression. Chest x-ray was without acute
changes. The patient was transferred to the intensive care unit (ICU)
with preliminary diagnoses of hypotension, elevated troponin and
atrial fibrillation.
During initial ICU assessment, a pulsatile abdominal mass was
noted. Urgent CT angiography revealed an 8.7 X 8 cm infrarenal
AAA with contrast leaking into the right common iliac vein and inferior
vena cava. The patient underwent emergent open repair of the
ruptured AAA and aortocaval fistula with grafting of the right iliac
and left common femoral arteries. The bowel was noted to be dusky
necessitating urgent left hemicolectomy and sigmoidectomy.
The patient returned to the intensive care unit where he remained
intubated but responsive. He continued to require pressor
support and required massive blood product transfusion. Within several
hours, evidence of ongoing bowel ischemia was noted with discussion
of further debridement of the bowel. The patient’s family declined
further aggressive care and the patient died approximately 30
hours after the initial syncopal event.
This case illustrates the importance of careful differential diagnosis
and thorough physical examination in the evaluation of patients
presenting with syncope. AAA rupture, with or without the rare complication
of aortocaval fistula, must be considered in the syncope differential
as the rapidity of diagnosis and surgical intervention significantly
impacts survival.
D23
Dementia and “Delirium” Due to Whole Brain Radiation in a
Cancer Survivor.
M. Elarabi, M. Brennan. Baystate Medical Center, Springfield, MA.
Introduction
Radiation therapy (RT) is important in treating CNS tumors.
Sufficient doses of RT eradicate neoplasms but will inexorably damage
normal tissue. Controversy persists around the impact of RT on
the adult brain. The authors report a case of a patient with recurrent
admissions for “delirium” that proved to be due to ongoing radiation
induced damage.
Case
A 67 year old man had a craniopharyngioma resection and RT
25 years ago; he had hypopituitarism, stroke, and dementia and was
admitted twice in a month with profound stupor and excessive daytime
sleepiness. On the first occasion he was intubated for airway protection.
The geriatrics team was asked to assess his delirium. His physical
examination was only remarkable for gait ataxia. His MMSE was
28/30; a Geriatric Depression Scale was negative but a urinalysis was
positive. An MRI revealed atrophy, old lacunar infarcts and chronic
white matter changes suggesting small vessel ischemia. A video EEG
revealed mild to moderate diffuse cerebral dysfunction. A
polysomnogram showed mild OSA and an irregular sleep cycle. His
cognitive impairment, hypersomnolence and loss of circadian rhythm
proved to be due to a damaged hypothalamic pituitary axis as a result
of his tumor and RT induced brain injury.
Discussion
There are 3 types of radiation injury: acute, early delayed and
late delayed. Late delayed injury is irreversible, occurs 6 months to
many years later and primarily damages the white matter causing atrophy,
leukoencephalopathy, neurocognitive decline and hypothalamic-pituitary
and endocrine dysfunction. The proposed etiology is
vascular and likely results from damage to capillary endothelial cells,
increased microvascular permeability and impaired blood brain barrier
integrity leading to ischemia. Analyzing the impact of RT is confounded
by injury from cerebrovascular disease, baseline impairments
in cognition and multifactorial interactions of tumor, surgery,
chemotherapy and steroids.
Conclusion
Tools to measure and identify radiation effects are underdeveloped.
Long term studies that carefully assess baseline cognition and
changes over time are critically needed or the eventual result of high
dose RT may be a demented, bedridden patient who is cancer free.
With more aggressive forms of RT and improved survival rates, geriatricians
will be seeing increasing numbers of elders with RT induced
cognitive injury. Geriatricians must learn to recognize and manage
the resulting deficits.
D24
Severe Consequence of Acquired Diaphragmatic Hernia After
Reconstructive Surgery for Chest Wound Dehiscence After
Coronary Artery Bypass Surgery.
M. Izhar, 1,2 A. Gupta, 1,2 F. Aziz, 1,2 R. J. Beyth, 1,3 M. K. Bautista. 1,2 1.
GRECC, NF/SGVHS, Gainesville, FL; 2. Dept of Aging and
Geriatrics, University of Florida, Gainesville, FL; 3. Dept of Medicine,
University of Florida, Gainesville, FL.
Introduction: Diaphragmatic hernia is a rare surgical complication
of reconstructive surgery for wound dehiscence after coronary
artery bypass surgery (CABG). This case illustrates anterior chest
wall hernia, a severe consequence of diaphragmatic hernia in an older
patient after CABG.
Case: A 70 year old man had CABG in 2007 which was complicated
by sternal wound dehiscence after severe coughing. Six days
after CABG, he underwent sternal debridement, omental transposition
and secondary closure of the mediastinum. Three weeks later, he
developed diaphragmatic hernia with the small bowel displaced into
the anterior mediastinum. He also developed anterior chest wall hernia
which grew over time to the size of 6x8 cm. In 2011 he was hospitalized
for acute cholecytitis. Two days after undergoing percutaneous
cholecystostomy tube placement, he developed acute abdomen. Exploratory
laparotomy revealed the cholecystostomy tube traversing
through the small bowel. The cholecytectomy tube was removed and
the small bowel was resected. Over the next 10 days, his anterior chest
wall hernia enlarged significantly to the size of 20x16 cm. CT scan of
chest revealed a large diaphragmatic hernia with the small bowel extending
up to the clavicles. He was not felt to be a surgical candidate
due to lack of acute respiratory distress and his significantly altered
anatomy. He was treated conservatively with indefinite use of the
chest binder and discharged home.
Discussion: Diaphragmatic hernia is a rare but recognized complication
after cardiothoracic surgery. Its published rates range from
2.7 % to 11.7%. During surgery, the omentum is transposed either
through an incision in the anterior diaphragm or through the upper
end of the laparotomy incision and a subcutaneous tunnel. The omentum
can reach the suprasternal notch, thereby allowing the reconstruction
of an extensive defect. In this case the surgical incision in
the anterior diaphragm may have been too large resulting in the gastrointestinal
herniation into the chest wall. Future studies are needed
to evaluate the risks and benefits of surgery such as this among older
adults who may have a high risk for post-operative complications
after CABG.
D25
The role of PC-MRI in the differential diagnosis between
Alzheimer’s disease and NPH.
J. Zmudka. Amiens University Hospital, Amiens, France.
Introduction:
AGS 2012 ANNUAL MEETING
S195