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Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 3A0 Case 3 History
Case 3 History ---- The patient had a past medical history of prostate cancer and hepatitis C. A gradual onset and decline in short term memory was thought to be consistent with an Alzheimer disease or frontotemporal dementia. He continued to have a gradual decline in cognition over the next few years. He developed marked cervical spondylosis (C5-C6) with severe spinal canal stenosis and possible normal pressure hydrocephalus (NPH). The patient was referred to neurosurgery for possible treatment of NPH. A right frontal ventricular shunt was placed in early August 2011. In September 2011, the patient sustained a fall with head trauma and facial lacerations. Head CT showed an interval decrease of ventriculomegaly, but also showed bilateral frontal subdural effusions up to 1.1 cm in thickness. Later, the patient sustained another fall and a repeat CT showed decreased ventriculomegaly, but also interval increase in the size of the subdural effusions (now 1.6 cm) and associated areas of high density, consistent with superimposed acute subdural hemorrhage. CT on 10/03 showed foci of additional acute hemorrhage along the right frontal convexity, falx, and tentorium. On 10/5 burr holes were placed for drainage of the subdural hematomas and to correct occlusion of the VP shunt. Follow-up CT on 11/03 showed resolution of the right sided subdural fluid collection, enlargement of the left subdural fluid collection, increased size of the lateral and third ventricles, and a mild (5mm) left to right midline shift. In late December, he was admitted again for communicating hydrocephalus and shunt occlusion. CT at that time showed decreased size of the left subdural effusion and increased size of the lateral and third ventricles and he underwent another shunt revision. In May 2012, he developed another subacute subdural hematoma and required another distal revision of the VP shunt. Acute hemorrhage was superimposed on chronic subdural hematoma and another subdural drain was placed. In June of 2012 CT showed moderate ventricular dilatation but no extracerebral fluid collections. He died in February of 2013. In summary, this patient had a progressive dementing illness over the course of approximately eight years but has a complex case with subdural hematomas, cystic hygromas, multiple surgeries, and head trauma, any of which could have contributed to further decline in cognition. ---- At autopsy, the fresh, unfixed brain weighed 1400g. The superior sagittal sinus and associated dura showed a 0.7 cm hemorrhagic mass occupying most of its cross sectional area. This lesion was composed of relatively dilated, irregular blood-filled spaces with walls of variable thickness. Underlying brain was not involved nor was there local significant hemosiderin deposition. The underside of the dura had patchy red-brown discoloration. Coronal slices revealed moderate dilatation of the lateral ventricles, thought possible residua of NPH. In addition, his brain parenchyma showed mild argyrophilic grain disease but no evidence of any other dementing or parkinsonian disorder other than a few neurofibrillary tangles in the medial temporal lobe unaccompanied by beta-amyloid plaques.
