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Washington University Experience | VASCULAR | Hemorrhage - Subdural | 19A0 Case 19 History
Case 19 History ---- The decedent is a 66-year-old man with a history of heavy tobacco use and metastatic poorly differentiated carcinoma of the lung involving multiple lymph nodes and bone. He was admitted February 8 with hypoxemia and dyspnea; a COVID-19 test was positive. Imaging showed new osseous lesions including a T3 pathologic fracture, and evidence of abdominal metastasis. A 1.1-cm left convexity subdural hematoma was incidentally discovered on CTA of the head and neck (not seen on January 19 imaging). On February 9, 2026, the patient sustained an in-hospital fall, resulting in a new acute right subdural hematoma. Neurosurgery recommended monitoring and middle meningeal artery embolization. On February 13, he developed acute clinical deterioration with altered mental status, tachycardia, leukocytosis, rising lactate, and increasing oxygen requirements. Repeat head CT showed progressive enlargement of the right subdural hematoma with increased midline shift. Planned embolization was cancelled due to hemodynamic instability, and subsequent imaging revealed a retroperitoneal hematoma and pericardial effusion, for which right adrenal artery embolization was performed. There was concern for coagulopathy and multiple blood products were transfused. His course was further complicated by respiratory failure requiring intubation, mucus plugging of the right lung, worsening intracranial hemorrhage, anemia, thrombocytopenia, and vasopressor-dependent shock. Despite optimal supportive care, he remained critically ill with progressive respiratory failure, coagulopathy (clinically suspected as a sequela of his metastatic cancer and nutritional deficiencies), and multiorgan instability. After a discussion with his family, he was transitioned to comfort care and died on February 15.
