case_images: PMC9769078_01
case_images: Overall patient's time line with GCS status: (a)- Initial and follow-up 2D-Echocardiographic paramters, FDP(ng/ml), and frequncy of myoclonic jerks. (b)- Variabilites in bio-physical(PaO2/FiO2 ratio) and bio-chemical parameters[D-dimer(mg/l), K+(mEq/L), pH(Log-H+)] with patient's progressing timeline. Mean and maximun values of D-dimer (mg/l), K+(mEq/l), and pH have been scaled between 0( as mean) and 1(as maximum). In case of K+, identified serum level of 2.67 has been considered minimum and 4.79 has been considered as maximum. (c)- Alterations in ventialtor support modes throughout the ICU admission phase.
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case_images: T-piece trial has been performed with low oxygen support from next day & subsequently on atmospheric oxygen (Figure 1C). D-dimer with fibrinogen degradation product (FDP) were also done which came out to be significantly high i.e., 32.5 mg/L & 1600 ng/ml respectively. During subsequent 2 days right RV systolic function gradually improved with tricuspid annular plane systolic excursion (TAPSE) values of 13 & 21mm and pulmonary arteriolar pressure (PAP) of 40 & 27mmHg respectively with normalizing IVC diameter and respiratory collapsibility on follow-up echocardiography (Figure 1a). On due course D-dimer level decreases gradually (Figure 1b).
case_images: Initial 2D-Echocardiography and Electrocardiography findings: (a)- Tranthorasic 2D-Echo with hugely dialated RA and RV(*) with compensated LV dysfunction. RV systolic dusfunction with apical sparing (McConnel's sign), dilated Pulmonary artery(PA), Low pressure TR( )), IVC diameter of 26mm with <30% respiratory collapsibility were also recorded. (b)- Repeat ECG on Day-2 showed T-wave inversion ( ) in chest leads (V1-V4) and significant S1 deepening.
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case_images: Transthoracic 2D-echocardiography (Figure 2a) showed hugely dilated right atrium (RA) and right ventricle (RV) with compensatory left ventricular (LV) dysfunction. LV function improved gradually with increased systolic ejection fraction (EF) on the following day after admission with repeat ECG findings of T-wave inversion in chest leads from V1-V4 & S-wave dipping in lead-1(Figure 2b).
case_images: NCCT-Brain and EEGs: (a)- Initial and repeat NCCT brain showed no significant changes. (b)- EEG showed initial Delta activity of 3-5 cycles/sec with followup findings of Theta activity of 5-7 cycles/sec, on both sides symmetrically and predominantly over P4-O2( ) and P3-O1( ). Normalisation of electrical activity was recorded subsequently with wellformed alpha activity on both sides symmetrically.
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case_images: Initial NCCT was done in order to rule out any underlying intra-cranial haemorrhage (ICH) and follow-up reports did not show any identifiable abnormalities (Figure 3a). Follow-up EEG revealed rhythmic well-formed theta activity (5-7 cycles/sec) on both sides, symmetrically over parieto-occipital areas with forward displacement on subsequent days (Figure 3b).
case_images: MRI and MR-Spectroscopic findings: (a)- MR-spectroscopy reveals reduction of NAA level with Lactate peaks in bi-lateral basal ganglia. Mild diffuse increase in Lactate peaks were also noted in multiple cortical areas. (b) -MRI reveals hyperintesity involving bi-lateral basal ganglia predominantly in caudate nucleus and ill-defined areas in bi-lateral cerebral hemispheres on FLAIR sequences( ) without any significant diffusion restriction.
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case_images: Upon significant improvement MRI with MR-spectroscopy was performed which revealed subtle FLAIR hyperintensity involving bilateral basal ganglia mostly in caudate nucleus & ill-defined areas in bilateral cerebral hemisphere without any significant diffusion restriction, suggesting progressive sequelae of hypoxic ischaemic encephalopathy (Figure 4b). MR spectroscopy there was reduction of N-acetylaspartate (NAA)-peak with increased lactate peak in bilateral basal ganglia. Mild diffuse increase in lactate-peak was also seen in multiple cortical areas; evidentially corroborating with HIE related changes (Figure 4a).