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Washington University Experience | VASCULAR | Edema - Cerebral | 4A0 Case 4 History
Case 4 History ---- The patient was a 14 year old male who was previously in good health. On 7/26 he was a middle front seat passenger and was unrestrained when his vehicle collided with a tree at approximately 45 mph. The patient reportedly got out of the vehicle and then collapsed with loss of consciousness and seizure activity. He was intubated at the scene and posturing with elbow flexion and ankle extension was noted. The patient was taken to a regional ER, where he was sedated and intubated. He was responding to simple commands. A head CT at that hospital showed no bleed, mass effect, or fracture. It did show mild cerebral edema and multiple bilateral frontal lobe punctate contusions. The patient was transported to SLCH ED without incident and was hemodynamically stable. There, he was combative and not following commands with a Glasgow coma scale of 7, moving all extremities. A head CT showed multiple contusions and diffuse axonal injury. The patient was admitted to the PICU with gross hematuria but CT scan showed no evidence of renal injury. The patient was also noted to have a positive Babinski sign at that time. On July 7 the patient withdrew to pain but did not respond to voice. There was no papilledema and he was hemodynamically stable. A head CT showed evidence of cerebral edema and an intracranial pressure monitor was placed. Over the next two days, the patient exhibited periods of hypertonicity with intermittent shivering and increases in intracranial pressure. He was also febrile with temperature to 39.4 and developed metabolic acidosis. A tracheal aspirate had 4+ Staph aureus and a blood culture grew Gram positive cocci in clusters. On July 30th the patient became hypotensive indicating possible sepsis, however he had good peripheral perfusion with a heart rate between 110 and 120. The patient had worsening respiratory status with new pulmonary infiltrates. Aggressive treatment with pressors was initiated and a Swan-Ganz catheter was placed. The patient developed a junctional/ventricular rhythm with ST depressions but with normal cardiac output. His heart rate decreased to the 50's and was given transthoracic pacing. His urine output ceased concomitant with a creatinine increase of 0.3 to 3.0. The intracranial pressure remained stable in the high teens. The patient then developed an isoventricular rhythm with no P-waves, wide QRS complexes and inverted T-waves. There was a rapid decline in blood pressure and heart rate and a cardiac rhythm could not be restored. ---- At autopsy the weight of the unfixed brain was 1,450 grams. He had traumatic encephalopathy characterized by diffuse axonal injury (DAI) and subarachnoid hemorrhage involving the cerebral hemispheres, brainstem and cerebellum, contusions particularly involving the frontal and temporal lobes, subdural hemorrhage and cerebral edema.
