Internal Carotid Artery Occlusion

lessness) 500 ml. of 20% mannitol was given to induce forced diuresis. 800 ml. of urine was excreted within the next two hours. Four hours after admission she was first noted to pass bloodstained urine. The movements increased in severity. Frequent heavy sedation with parenteral soluble sodium phenobarbitone, 3 gr., and paraldehyde, 10 ml., was required to control restlessness. This state continued for the next four days with no change in the depth of consciousness. Pupils were sluggishly reactive and secretions from the oropharynx were mechanically aspirated. Thirty hours after admission she was noted to have widespread purpura on her back, buttocks, and front of thighs. There was also a small haemorrhage in the conjunctival vessels in the right eye. Fundoscopy revealed no haemorrhage or papilloedema. Owing to this bleeding tendency, intravenous fluids were withheld and nutrition was maintained by gastric tube. Occasionally blood was aspirated through this tube. Other supportive therapy consisted of highpotency vitamins and vitamin K, 10 mg. intramuscularly daily for four days. She continued to be very restless, with marked opisthotonos at times. There was no neck rigidity. A lumbar puncture revealed clear fluid at normal pressure with no significant biochemical changes. Urea and electrolytes were normal. On the fifth day after admission the first sign of response was noticed by the opening of her eyes on demand. She asked for a cup of tea. Gradual recovery then occurred. At first she was unable to co-ordinate her hands, but this slowly improved. There has been no residual weakness, incoordination, or peripheral neuritis. Plantar responses had reverted to normal. Haematuria and purpura gradually cleared from the third day onwards. There was euphoria for a couple of days after return of consciousness, but this has since settled and all higher functions are now normal. She confessed having taken the tablets deliberately because of cancerphobia.