A 69-year-old male transferred to the Johns Hopkins MICU with confusion and slurring of speech.

Eight days prior to admission, the patient was seen by his primary care physician for dyspnea, thought to be an exacerbation of his known chronic obstructive pulmonary disease (COPD). During his evaluation for dyspnea, he was noted to have an INR elevated to 5.0. The patient was taking coumadin for the past 5 years since an aortic valve replacement. Coumadin was held and the patient awoke several days later with confusion and slurring of speech. He was seen at an outside hospital where a CT scan showed multiple hyperdense lesions in the brain. The patient was transferred to The Johns Hopkins Hospital, during which he had an episode of bradycardia and hypotension. He was admitted to the Medical Intensive Care Unit. Repeat head CT scan at JHH showed multiple hyperdense, presumed hemorrhagic lesions (Image 1).

The patient has COPD secondary to an 80 pack year history of tobacco abuse. Patient has a history of an episode of pneumonia, unstable angina, and aortic stenosis.

Aortic valve replacement (1997).
Carotid endarterectomy (2000).

Family history is non-contributory.

The patient lives in Bermuda with his wife.

Coumadin
Atorvastatin
Prilosec
Lasix
Aldactone

NKDA

Patient has confusion, slurring of speech.

* The patient is a well-nourished male who is orally intubated, sedated, and mechanically ventilated.
* Vital signs: T=38.5 C, HR=110, RR=16, BP=80/40. Oxygen saturation is 70-80% on room air.
* Head and Neck: The eyes show mild conjunctival injection. Examination of the oropharynx reveals poor dentition, but no obvious signs of infection. There is shotty cervical lymphadenopathy.
* Pulmonary: There are decreased breath sounds at the left base without wheezing.
* Cardiovascular: tachycardia, mechanical heart valve heard.
* Abdomen: soft and nontender; no hepatosplenomegaly.
* GU: mild shotty inguinal lymphadenopathy bilaterally.
* Neurologic exam: sedated for mechanical ventilation, no signs of seizure activity, pupils are equal and round without papilledema. There are no gross motor or reflex defects but the patient can not cooperate with voluntary testing. Toes are downgoing.
* Skin: Legs show ecchymoses.

WBC 11,860, Hemoglobin 13.7, Glucose 174, Creatinine 1.7, Albumin 3.1, ALT 140, AST 283, serum CK 1549 IU/L, CK-MB 211. Blood cultures- no growth

Changes suggestive of antero-lateral and inferior ischemia.

CT scan of the head shows multiple hyperdense lesions in the cerebellum, temporal, frontal and occipital lobes (Image 1). Chest X-ray shows diffuse bilateral infiltrates and cardiomegaly (Image 2).

The patient was found to have an ejection fraction of 15-20% by echocardiogram, with anterior wall dyskinesis, severe posterior and inferior wall hypokinesis, and lateral wall akinesis. Despite treatment with dopamine, norepinephrine, phenylephrine, dobutamine, and vasopressin, the patient's blood pressure remained near 80 systolic and 40 diastolic. Despite ventilator support, his oxygen saturation remained at 70-80%. Stool, urine, and blood cultures were negative. Given the poor prognosis, a decision was reached to make the patient DNR, and he expired shortly thereafter.

What is the most likely cause of the patient's neurologic findings?
What is the most likely cause of the patient's demise?