Man with post-operative cognitive impairment

A 47-year-old Caucasian man was referred due to memory problems and depression following surgical treatment of aortic dissection 1 year earlier. After surgery, he was unable to return to work and began receiving disability benefits. History One year ago this man arrived at the ER complaining of chest pain radiating to the back and abdomen, head and neck, and blurred vision with visual "spots." He provided a reasonable history; speech and cursory neurological examination were normal. Despite no previous history of hypertension his Blood Pressure (BP) was 160/90 mm Hg. He became confused and hypotensive (systolic BP: 70 mm Hg). He was not tachycardic and extremities were warm with good femoral pulses. Myocardial infarction was ruled out. Computerized Tomography (CT) of the chest showed aortic dissection starting in the aortic root and extending to the arch and descending aorta with exit around T12. The aortic valve was not involved. Hemopericardium was confirmed by 2D echocardiogram. He immediately underwent successful surgical treatment complicated by bradycardia and hypotension requiring admission to the Coronary Care Unit (CCU). In the immediate post-operative period he became agitated and selfextubated himself; later, in the CCU, he was found to have episodic twitching of the right side of the face and the right hand. On initial neurological examination, there was limited movement of his right upper limb but frequent convulsive movements on the right leg were present. He was treated with a loading dose of 20 mg/kg of fosphenytoin intravenously. An Electroencephalogram (EEG) revealed numerous partial seizures originating from the left frontal region, consistent with non-convulsive status epilepticus.