Ataxic breathing in neurocritical care: malignant cerebral infarction without evident brainstem lesion on serial ct a case report

Abstract

Introduction: Biot’s breathing, an ataxic pattern, is characterized by irregular ventilation with variable tidal volumes and unpredictable apneic pauses. It is classically associated with medullary lesions; however, it may occur without focal brainstem injury in extensive hemispheric infarctions with dysfunction of the central respiratory network.

Objective: To describe the case of a neurocritical patient with a right malignant hemispheric infarction who developed Biot’s breathing documented on mechanical ventilation, without evidence of structural involvement of the medulla or pons on serial neuroimaging.

Case presentation: A 90-year-old woman was admitted to the ICU with an initial diagnosis of non-traumatic subdural hemorrhage and pneumonia. Computed tomography showed an extensive right hemispheric infarction with edema and midline shift. During her course, she developed a pattern consistent with Biot’s breathing, demonstrated on ventilator waveforms, despite follow-up neuroimaging showing no involvement of the medulla or pons. She required prolonged invasive mechanical ventilation, with tracheostomy and gastrostomy, and remained in a stationary neurological phase with a reserved prognosis.

Discussion: The occurrence of Biot’s breathing without visible bulbar lesions supports a mechanism of functional dysfunction of the respiratory network due to mass effect and diffuse brain injury. This pattern should be interpreted as a multicausal syndrome with reversible and irreversible etiologies, which shapes ventilatory strategy, limits weaning, and requires clear prognostic communication and shared decision-making with the family. It provides objective ventilatory documentation in the ICU.