Ischemic Stroke and Seizure as Complication from Inadvertent Intra-Arterial TPN Infusion: A Case Report

PICC linesare increasingly common in the hospitalized patient. Catheter misplacement is a recognized complication of PICC insertion. This article describes a unique case of stroke accompanied by nonconvulsive status epilepticus (NCSE) as a result of total parenteral nutrition (TPN) continuously infusing from a peripherally inserted central catheter (PICC) in a patient's aorta. A 58 year old woman presented to an outside hospital for a small bowel obstruction. A PICC line was placed under ultrasound guidance and con irmatory chestx-ray (CXR) showed “left-sided PICC line terminating in persistent left SVC.” Upon arrival at our institution, repeat CXR con irmed this placement. On day two of hospitalization, the patient was initiated on a continuous infusion of TPN. Thirty minutes later, the patient developed severe headache, confusion, and dysphasia. Initial assessment revealed an NIHSS of 4, but no focal motor de icits. Over the next 24 hours, the patient developed obtundation, left-sided hemiparesis, and abnormal movements. CT angiography revealed the PICC line terminating in the aorta. The PICC line was removed. Brain magnetic resonance imaging (MRI) demonstrated multiple foci of restricted diffusion and EEG later revealing NCSE. Further evaluation including transthoracic echocardiography did not reveal any additional cause of stroke. In patients with a con irmatory CXR suggesting unusual or anatomically variant central line positioning, additional modalities should be considered to con irm placement. Clinicians should be aware of arterially infused TPN as a cause of stroke with progressive accumulation of neurological indings.