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Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 11A0 Case 11 History
Case 11 History ---- The patient was a 50 year old man with history of hypertension, coronary artery disease status/post stent placement, alcoholism, tobacco use (at least 1 pack per day) and depression. On 4/10 he presented to an OSH requesting detoxification, complaining of suicidal ideations and increased drinking up to a fifth of whisky daily. He was given multivitamins, folic acid, thiamine, and 1 g of magnesium sulfate. There was no evidence of active withdrawal or active toxidrome. The patient was given a total of 4 mg Ativan (lorazepam) intravenously for comfort. At time of admission, he complained of episodic chest discomfort. After medical clearance, the patient was admitted for psychiatric care and detoxification. On 4/11 he complained of the worst headache of his life. He was given 2 mg intravenous Ativan x2 and became more lethargic with slurred speech. He was later found unconscious in his room, not responding to any stimuli; his Glasgow Coma Scale score was 4. There was a suspicion for an unwitnessed traumatic fall. His blood pressure was 210-220 systolic and 100-120 diastolic, with a heart rate in the 40s. A head CT scan showed a large, likely ongoing right subdural hemorrhage and extremely severe right-to-left shift, right uncal and transtentorial downward herniation. There was also evidence of edema and sulcal effacement. The patient was emergently intubated, given 100 mg mannitol and transferred to BJH for immediate neurosurgical intervention. On arrival to the ICU, the patient was comatose, intubated, with nonreactive bilateral pupils, absent brainstem reflexes, no response to sternal rub and triple flexion of the lower extremities. A repeat head CT showed worsening subdural hemorrhage with midline shift. The Neurosurgery service determined the patient was not a candidate for surgical intervention. The family decided to redirect care and the patient expired on 4/12. ---- At autopsy the weight of the unfixed brain was 1390g. Gross and microscopic examination of the brain, spinal cord, and dura show a large (~200 mL) acute right subdural hemorrhage, accompanied by cerebral edema, multifocal infarction, and subfalcine as well as uncal herniation with resultant secondary brainstem (Duret) hemorrhages. A precise etiology for the initial subdural hemorrhage could not be discerned on the basis of the neuropathological examination alone. There was suspicion for an unwitnessed traumatic fall or an acute spontaneous subdural hemorrhage, the etiologies of which are diverse.
