Man-in-the-barrel syndrome in a noncomatose patient: a case report

A 62-year-old man developed man-in-the-barrel syndrome (MIBS) after emergency four-vessel coronary artery bypass surgery. MIBS refers to the clinical syndrome of bilateral upper extremity paresis with intact motor functioning of the lower extremities, giving the appearance of being confined within a barrel. The pathogenesis of MIBS is believed to be cerebral hypoperfusion leading to border zone infarctions between the territories of the anterior and middle cerebral arteries. Physical examination revealed bibrachial paresis, decreased upper extremity tone, mild left central VII palsy, flat affect, mild cognitive deficits, and poor balance while ambulating. An EMG showing poor motor unit recruitment and slow-firing motor units, and abnormal SSEPs indicated an upper motor neuron lesion. There was good progress in physical and occupational therapy, and good return of upper extremity function in four months. Only 11 cases of MIBS have been reported, all of whom were comatose; ten died. Our patient was never comatose and had good functional recovery.