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Washington University Experience | VASCULAR | Atherosclerosis | 5A0 Case 5 History
Case 5 History ---- The patient was a 51-year-old man with a history of untreated hypertension. He presented on 12/14 with acute onset of headache and neck pain. His initial systolic blood pressure was recorded as 268. Over the course of three hours, the patient had rapid deterioration in mental status and developed complete left hemiparesis. Initial head CT demonstrated diffuse subarachnoid blood clot in the right Sylvian fissure as well as hydrocephalus. Complete blood count and coagulation studies were normal. The patient was emergently intubated and an external ventricular drain was placed. Due to concern for seizure activity, treatment with levetiracetam was initiated. A four vessel cerebral angiogram performed five hours after presentation demonstrated active extravasation from multiple foci of the right middle cerebral artery with contrast-fluid levels within the right sylvian hemorrhage. By eight hours after presentation, he was noted to have unequal pupils and treatment with mannitol was initiated. Despite ongoing treatment with mannitol and hypertonic saline, he demonstrated steady loss of brainstem function over the next two days. The patient’s blood pressure was consistently greater than 180 systolic and 100 diastolic. A CT scan on 12/16 demonstrated interval worsening of midline shift (reaching 2.8 cm displacement) with extensive subarachnoid, intraventricular and intraparenchymal hemorrhage. A cerebral blood flow study on 12/17 demonstrated no effective cerebral perfusion and the patient passed away. ---- At autopsy the weight of the unfixed brain was 1270g and showed a recent large hemorrhage involving the right basal ganglia/thalamus with extension into adjacent right frontal, parietal, and temporal lobes. Subarachnoid hemorrhage was diffuse and parenchymal edema contributed to herniation of the right cingulate gyrus and uncus resulting in Duret hemorrhages and anterior-posterior elongation of midbrain. Hypoxic/Ischemic damage was widespread involving the neocortex, hippocampus, cerebellum, basal ganglia and brainstem. Severe small vessel arteriolosclerosis and severe large and small artery atherosclerosis was found.
