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Washington University Experience | VASCULAR | Herniation, tonsillar | 11A0 Case 11 History
Case 11 History ---- The patient was a 71 year old woman with a long history of COPD, DVT treated with Coumadin, sinusitis, bronchitis and rheumatoid arthritis treated with prednisone. The patient presented on 11/18 with increased shortness of breath, pleuritic chest pains, sweats, weakness and right lower extremity edema. During her VQ scan on the day of admission she had a respiratory arrest and required intubation. Right lower lobe pneumonia and worsening COPD was treated with antibiotics and aggressive bronchodilator treatments. Pulmonary status had improved through her hospital course and she was then extubated on 11/21. Lower extremity Doppler examination revealed deep vein thrombosis involving the right popliteal vein was occluded but it was unclear if this was a new or old. Because of her initial supra therapeutic PT level her Coumadin was held and she was treated with subcutaneous heparin until her PT level normalized and then was treated with heparin and coumadin. Interventional radiology was consulted for placement of a filter and her coumadin and heparin were discontinued on 11/26 on the day prior to the placement of the filter. However, on the morning of 11/27 the patient became obtunded. Head CT showed a large left cerebellar hemorrhage with mass effect and ventricular obstruction with hydrocephalus. The patient opened her eyes to pain but did not follow any commands. Her pupils were 4/4, round and reactive to light. She had a right gaze preference. Glasgow coma scale was 8. That afternoon the patient was taken to the OR emergently to evacuate the left cerebellar hematoma. Prior to beginning the operation she had very difficult airway ventilation and was hypotensive. Her blood pressure was controlled while on pressor agents. The emergent posterior fossa craniectomy was performed hemodynamically. She was stable during the procedure. After the procedure was completed, the patient suffered sudden cardiac arrest followed by sinus bradycardia and a second arrest; chest compressions were performed but she did not survive. ---- At autopsy the brain weighed 1400 grams. There was residua of craniotomy involving the posterior fossa for evacuation of cerebellar hemorrhage and shunt placement in the right lateral vehicle, with recent hemorrhage into the left cerebellar hemisphere and subarachnoid space.
