"Locked-in" syndrome.

To the Editor: It was with great interest that we read the recently published (MayJune 1986) letter from Drs. Buchman and Wichter in which they described a patient who recovered from "locked-in" syndrome. We had the opportunity of seeing a patient who developed multiple episodes of the "locked-in" state from which he always recovered completely. The patient was a 71 -year-old man with a long history of chronic obstructive pulmonary disease for which he had just been admitted. He suddenly became mute and completely immobile and was only able to close his eyelids and move his eyes horizontally on command. He was not able to move his tongue or swallow. At the time of the episode his blood pressure was 100/60 torr. CT scan of the head was normal. The event resolved completely within a few hours, and the patient became neurologically normal. After regaining his ability to speak, he related a history of having had two or three similar episodes within the previous week. The patient was treated with intravenous heparin, and attempts were made to keep his systolic blood pressure above 130 torr. He was considered to be a poor risk for long-term anticoagulation owing to his overall debilitated health. Heparin was therefore discontinued after 2 weeks, and he was started on aspirin. After 2 more weeks of observation, he was discharged home without any further episodes. We think that our patient had reversible "locked-in" syndrome secondary to vertebrobasilar insufficiency, which decompensated after periods of hypotension. We postulate that the "locked-in" state cannot only be reversible, but it may also recur as the result of multiple episodes of transient vertebrobasilar ischemia.