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Washington University Experience | VASCULAR | Herniation, tonsillar | 10A0 Case 10 History
Case 10 History ---- The patient was a 41 year old woman admitted to an OSH in February, 1984 with a two month history of headache. Weakness of the left and right lateral rectus muscles was found. CSF revealed pleocytosis (mainly polys), an increased protein content and decreased sugar content. In addition, a head CT showed a mass in the left thalamus and a possible lesion in the cerebellum. Because of a past history of a positive PPD and the spinal fluid results, she was begun on broad spectrum antibiotics and anti-tuberculosis therapy. However, there was no improvement on this treatment and the spinal fluid smears and cultures for organisms remained negative. Repeat LP pleocytosis changed to predominantly mononuclear cells. She had normal mental status and speech. On April 8 she abruptly became weak again and was readmitted. She displayed forgetfulness and confusion, as well as emotional lability. She had bilateral ptosis and markedly limited eye movements with dilated and fixed pupils. Meningeal rigidity was present. Late on the evening of admission the patient was found unresponsive. CPR was performed and one hour after the arrest she was awake, moving her upper extremities, left better than right. She had roving movements of her eyes. Pupils were still fixed and dilated. However, three hours later she was described as having no spontaneous movements of her extremities, no response to deep pain, no corneal reflexes, and no spontaneous respirations. She was taken off the respirator for three minutes and had no spontaneous respirations. On 4/14 a brain death study was performed and following removal from the ventilator on 4/15 there were no spontaneous respirations and she was pronounced dead. ---- The autopsy in this case showed a large pulvinar tuberculoma and severe tuberculous meningitis involving the base of the brain including the cerebellum and brainstem with edema and microinfarction of the central medulla. The cerebellar herniation involved the biventral lobule in this case as well as the tonsils. In this case a combination of intrinsic pathology likely combined with a crowded posterior fossa/foramen magnum to result in the patient's demise.
