Table of Contents
Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 14A0 Case 14 History
Case 14 History ---- The patient was an 86 year old right-handed man with a two week history of progressive generalized weakness and falls and a four day history of bowel and bladder incontinence who presented to the ER with increased confusion after another fall. The patient's past medical history is significant for prostate cancer (S/P radical prostatectomy 15 years prior), hypertension, and coronary artery disease. His right pupil was reactive, his left was 8 mm and non-reactive. His extraocular movements were full on the right, but not on the left. He had mild proximal weakness of the right leg and moderate, diffuse weakness of the left leg. Sensation was intact and reflexes were symmetric throughout with downgoing toes bilaterally. Evaluation of the patient's progressive deteriorating mental status included a head CT which revealed a large intracranial hypodense fluid collection with areas of hypodensity and a 1.2 cm left to right midline shift consistent with a chronic subdural hematoma with subacute and acute components. Further evaluation revealed an elevated PT and he was given vitamin K and FFP. He later underwent a twist-drill craniotomy and insertion of a subdural catheter for drainage of the left-sided subdural hematoma. The next day the patient was noted to have improved somewhat neurologically with no headache and improved right-sided strength. He remained neurologically stable through the remainder of his hospitalization despite significant residual hematoma. On 4/12 the patient became apneic. CPR was initiated, but he did not respond to resuscitative measures and died later that day. ---- At autopsy, the weight of the unfixed brain was 1200g. A subdural hematoma measuring 9 x 8 x 1 cm, was present in the left parietal-temporal-occipital lobe which may have resulted from multiple falls. When sectioned, the blood clot between the dura and the membrane appeared somewhat heterogeneous histologically, possibly originating from different episodes of hemorrhage. There is subfalcine herniation. Histologic evidence identifies the presence of idiopathic Parkinson's disease but not neocortical Lewy bodies and only mild Alzheimer Disease Neuropathologic Change.
