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Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 16A0 (Case 16) History
Case 16 History ---- The patient was a 54-year-old woman with multiple sclerosis (diagnosed in April 2003). In May 2005 she presented with nausea, vomiting and abdominal distension having lost 20 pounds over 2 months unintentionally. A palpable mass in the left lower abdomen was found treated by TAH/BSO. Two large lymph nodes in that surgical specimen contained high grade B-cell lymphoma. Post-operatively, the patient improved, but 1 month later started to develop slowly progressive mental decline, characterized by sleepiness, dysarthria and generalized weakness. Admitted on 7/11 with these symptoms, she was seen by Neurology who concluded that mental status changes would most likely be caused by hypercalcemia, acute renal failure and possible meningeal involvement. CSF was positive for lymphoma. Therefore, the patient started to receive chemotherapy with rituximab, cyclophosphamide, mesna, doxorubicin, vincristine and intrathecal cytarabine. She developed pancytopenia, then suffered respiratory failure and was intubated. Finally, the patient developed Steven-Johnson syndrome (likely secondary to drug Rx) with a gastrointestinal bleed, mucositis and bilateral corneal abrasions. She developed a neutropenic fever due to enterococcus bacteremia. The patient received multiple blood transfusions. At the end of this complicated course, she was extubated and transferred back to the floor on 8/10. On 8/13 she developed cardiopulmonary arrest from which she was resuscitated and was transferred to the ICU with pupillary abnormalities and myoclonus. Head CT scan showed a right-sided subdural hematoma with 4 mm midline shift. Also there was decrease of grey-white matter differentiation and a hypodensity of central pons. The conclusion was that the patient suffered anoxic brain injury and for that reason received terminal wean, extubation and morphine drip on 8/18 and died on 8/22. ---- At autopsy, the weight of the unfixed brain was 1298g. The dura and the leptomeninges were covered with a layer of blood clot which spans most of the cortical surface. The subdural hematoma also showed focal areas with organization. The thickness of the blood clot measures 1.5 to 2.0 mm. ---- Findings consistent with multiple sclerosis (chronic inactive), chiefly involving spinal cord and optic nerves/chiasm, and central pontine myelinolysis (CPM). In addition, there was diffuse hypoxic-ischemic changes, recent and subacute, ranging from selective neuronal necrosis to incipient infarction, involving the cerebral hemispheres, deep gray nuclei, brainstem and cerebellum. There was no evidence of metastatic or primary CNS lymphoma noted. The presence of subdural hematoma was confirmed but without definitive evidence of uncal herniation. It was speculated that the extensive subdural hemorrhage noted in this patient may be the result of thrombocytopenia following chemotherapy.
