Stroke Patient Pronounced Brain Dead Following Naloxone Treatment

Case Overview

This case involves a 56-year-old female with a history of hypertension who presented with complaints of extremity and tongue numbness as well as slurred speech. Upon evaluation, it was noted that the patient had signs of left facial droop. A CT scan was ordered. The CT demonstrated evidence of an acute hemorrhage in the right basal ganglia. Following the CT, the patient’s symptoms worsened and she became non-verbal. Naloxone was ordered, and the patient began thrashing in pain and pointing to her lower back. The physician who ordered the Naloxone arrived at the bedside and checked the patient’s blood pressure, which had become extremely elevated. The patient was sedated and then intubated. A subsequent CT revealed a large intraparenchymal hemorrhage and cerebral herniation. The following day, neurosurgery performed a craniotomy on the patient but she was declared brain dead shortly after the procedure.

Questions to the Neurology expert and their responses

Do you routinely manage patients that present with cerebrovascular events in evolution?

I am a full-time neurointensivist caring for patients at an academic medical center with catastrophic neurological illness and injury. I routinely manage such patients, as approximately one-third of our admissions to my 17-bed neuroscience ICU involve strokes in evolution, both acute ischemic strokes and intracerebral (ICH) hemorrhagic strokes. I have also given many teaching series and grand rounds on ICH to my colleagues in neurocritical care, residents, fellow neurologists, and medical students.

What role would you conjecture Naloxone played in his deterioration if any?

Naloxone likely caused him an abrupt increase in pain (previously I presume on analgesics, which Naloxone reversed) which caused an acute rise in blood pressure, a known risk factor for expansion of an intracerebral hematoma. Current recommendations are to drop and maintain systolic blood pressure less than 140. The administration of Naloxone also likely delayed appropriate therapy.

About the expert

This expert has over 30 years of experience in the field of neurology and neurocritical care. She earned her BA in philosophy from Oberlin College and her MD from Case Western Reserve University School of Medicine. She then completed a residency in internal medicine and a second residency in neurology at the University of California, San Francisco, followed by a fellowship in neurocritical care at the University of Cincinnati. Today, this expert is board certified in both neurology and neurocritical care. She is an active member of several professional societies, including the American Academy of Neurology, the Neurocritical Care Society, and the Society for Critical Care Medicine. This expert previously was the director of the headache and pain clinic at the University of Kentucky, the medical director of the Kentucky Neuroscience Institute, and an associate professor of neurology at Case Western Reserve University and the University of Kentucky. Currently, she serves as a professor of neurology and neurocritical care at a university and as an attending neurologist at a university-affiliated medical center in Oregon.

E-036010

Specialties:

Neurology