A Case of Recurrent Aspiration Pneumonia and Hyperosmolar Hyperglycemic State Following Severe Stroke and Its Management With Radiologically Inserted Gastrostomy (RIG) Tube Placement

TL;DR

A man with severe stroke, diabetes, and aspiration pneumonia had limited recovery despite RIG tube placement to manage feeding and reduce lung infections.

Contribution

This case highlights the use of RIG tubes in managing aspiration pneumonia and vascular access challenges in severe brainstem stroke patients.

Findings

RIG tube placement reduced the frequency of aspiration-related chest infections.

The patient's condition stabilized temporarily after RIG tube insertion.

Neurological and functional recovery remained limited despite interventions.

Abstract

This report describes the case of a 65-year-old previously healthy man who presented with a severe left pontine ischaemic stroke, resulting in significant neurological deficits and a prolonged hospital stay. He had a pre-morbid modified Rankin Score of 0, with a background of type 2 diabetes mellitus (HbA1c 86 mmol/mol), a history of smoking, recurrent vomiting, and oesophagitis. During admission, he developed frequent episodes of aspiration pneumonia, which significantly complicated his recovery. His Glasgow Coma Scale (GCS) remained low (E4M6V1) throughout, indicating limited neurological improvement. Posterior circulation strokes involving the pons are particularly severe due to the concentration of cranial nerve nuclei and vital autonomic pathways in this region. His clinical course was further complicated by the development of a hyperosmolar hyperglycaemic state (HHS), requiring medical management. As his condition progressed, peripheral venous access became increasingly difficult, eventually necessitating central venous catheter insertion. Following the placement of a radiologically-inserted gastrostomy (RIG) tube, the frequency of aspiration-related chest infections reduced, and his condition temporarily stabilised. However, his overall neurological and functional recovery remained limited. He was eventually discharged to a nursing home but sadly passed away several months later due to ongoing complications. This case highlights the challenges in managing patients with severe brainstem strokes complicated by recurrent aspiration pneumonia, metabolic disturbances such as HHS, and vascular access difficulties. It also reflects the potential role of RIG feeding in reducing respiratory complications in patients with severe dysphagia.

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