Too Aggressive Drop in Blood Pressure in a Hypertensive Male Leading to “Man-in-the-Barrel Syndrome”

Abstract

Introduction. “Man-in-the-barrel syndrome” is a neurological phenotype with brachial diplegia, normal sensation, and preserved motor function of the lower limb. It has been described in various neuropathological conditions affecting the cerebral hemispheres, pons, upper spinal cord, and peripheral neurons. Severe hypotension leading to watershed infarctions leading to this phenotype has been reported. We describe the first case of “man-in-the-barrel syndrome” in a patient with a precipitous drop in blood pressure following oral antihypertensive medications. Case Presentation. A 75-year-old Sri Lankan male presented following a generalized tonic-clonic seizure to a tertiary care hospital. Upon recovery, he was noted to have severe brachia diplegia affecting shoulder movements with preserved hand muscle power and motor functions of the lower limb. The previous day, he was newly diagnosed with markedly elevated blood pressure without acute end organ involvement. Treatment with three antihypertensives had been initiated. Noncontrast CT of the brain revealed watershed infarctions affecting both cerebral hemispheres. Conclusion. It is generally unwise to lower blood pressure very rapidly, as ischemic damage can occur in vascular beds that are habituated to high levels of blood pressure in the brain. Ischemic damage caused by rapid lowering of blood pressure may rarely result in “man-in-the-barrel syndrome” leading to severe functional disability.

Man-in-the-Barrel Syndrome Secondary to Idiopathic Acute Anterior Spinal Artery Infarction

“…MIBS is a rare neurological syndrome often associated with cerebral hypoperfusion, which can occur in conditions such as systemic hypotension, cardiac arrest, following major cardiac surgery, or rapid correction of hypertension, and can lead to bilateral ischemic watershed strokes [5][6][7]. In addition to the aforementioned causes, supratentorial injuries can also be caused by cerebral metastases [8] and closed head injuries [9].…”