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Washington University Experience | VASCULAR | Hemorrrhage - Subdural | 9A0 Case 9 History
Case 9 History ---- The decedent was a 6 year old male child with a past medical history of a suprasellar adamantinomatous craniopharyngioma, status-post subtotal resection in 02/2013, followed by radiation treatment. His course was complicated by cystic growth of the residual mass (requiring fenestration in 2014), bilateral painless vision loss (treated with left subfrontal craniotomy and optic nerve decompression in January 2015), left transverse sinus venous thrombosis with punctate areas of restricted diffusion in the left corpus callosum and left posterior frontal lobe, radiologically consistent with acute infarcts (02/2015), panhypopituitarism, diabetes insipidus, central hypothyroidism, secondary adrenal insufficiency, and hypothalamic obesity. He had hydrocephalus with bilateral subdural fluid collections (hygromas) which had been very difficult to treat; he had had an external subdural drain on the left, subsequently converted to a subdural to peritoneal shunt. On 2/16, the decedent was at home and had abnormal breathing while getting dressed by his parents. He had a brief “jerking” episode and abnormal stare. Emergency medical services (EMS) was called and arrived within 10 minutes; they found the decedent pulseless and in asystole. Blood glucose of <20 was drawn within 2 minutes of CPR initiation. CPR was initiated unsuccessfully for ~1 hour during transport by EMS and after arrival at BJH but the patient did not survive. ---- At autopsy the skull showed multiple bur holes, frontal craniotomy and two catheters: one, on the left, terminating in the vicinity of the dura; another, in the right superior frontoparietal region, penetrated the cortex. Bilaterally, the dura mater shows sanguineous discoloration, consistent with subdural hemorrhage, as well as internal, blood-free, smooth-walled pockets, consistent with hygromas. ---- Coronal sections of the hemispheres showed moderate dilatation of the lateral ventricles (right greater than left) and third ventricle, and a catheter entering from the right frontal cortical surface, descending lateral to the right lateral ventricle. The suprasellar parenchyma surrounding and anterior to the third ventricle appears gray, somewhat soft and gelatinous, and has focal chalky areas consistent with calcifications. Microscopic appearance of this area showed residual/recurrent elements of craniopharyngioma, with epithelium and wet keratin with surrounding radiation effect (hyalinized vessels, rarified neuropil), perivascular and scattered foamy macrophages, robust piloid gliosis, and focal lymphocytic infiltrate. ---- Sections of the dura showed a collagenous dura with a focal Y-shaped bifurcation and a smooth lining, consistent with the peripheral edge of a hygroma. The other surface of the dura showed reactive changes and granulation-like tissue, consistent with remote subdural hematoma. The decedent was known to have a clinical history of seizures, secondary adrenal insufficiency and ADH insufficiency/diabetes insipidus (contributing to recorded hypernatremia in the months before death). Given the available clinical information on the day of expiration, it would appear likely that electrolyte abnormalities, hypoglycemia (secondary to hypothalamic/pituitary dysfunction), and seizure propensity (associated with craniopharyngioma and mesial temporal sclerosis), may have played a role in his demise.
