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Washington University Experience | VASCULAR | Cavernous Angioma | 2A0 Case 2 History
Case 2 History ---- The patient was a 53 year-old, male with past medical history of systemic amyloidosis and Hodgkin's lymphoma status post XRT in the 1970s, as well as hypertension, who has had significant stenosis of the neck vasculature and airway resulting from remote radiation therapy. He presented to BJH for a vascular surgery procedure (June 2007) involving decompression of a left-sided thoracic outlet syndrome and clamping of the left vertebral artery for 31 minutes for left subclavian-to-axillary bypass. Postoperatively as he awoke from this procedure, he was found to be dysarthric and have double vision with dysconjugate gaze. His initial exam was consistent with brainstem strokes and head CT done immediately showed a relatively large left cerebellar infarct, as well as infarct involving the right cerebellum and brainstem. He received a neurointerventional angiogram, which demonstrated chronic right-sided common carotid occlusion as well as a left external carotid occlusion. There was a thrombus in the distal third of the basilar artery. It was then noted that the patient had a dilated right pupil, but was following commands. At that point a repeat MRI/MRA was performed which revealed new infarcts in bilateral thalami, right midbrain, hypothalamus and right occipital hemisphere with no extension of known basilar tip thrombus. The patient developed coffee ground emesis while an esophagogastro-duodenoscopy revealed trace erosions of the mucosa with no active bleeding. The remainder of the patient's hospital stay was complicated by respiratory failure. The patient required a tracheotomy for airway support. He developed sudden onset of a drop in oxygen saturations associated with hypotension. A chest tube was inserted for a large left pleural effusion and the patient was started on levophed for pressor support. The patient subsequently lost pulse, was coded for cardiac arrest and did not regain a pulse in spite of code medications.
