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Washington University Experience | VASCULAR | Herniation, tonsillar | 2A0 Case 2 History
Case 2 History ---- The patient was a 54 year old woman with a history of hypertension who was transferred from an outside hospital with a 4-6 week history of a productive cough, fatigue and dyspnea. She was begun on IV antibiotics for pneumonia however a CBC demonstrated pancytopenia with a white blood count of 1 .8 and a hematocrit of 23.3 and 47,000 platelets. The patient was therefore transferred to Jewish Hospital where she was to undergo a bone marrow biopsy; however the patient became acutely aphasic with a right hemiparesis. A CT scan demonstrated a left fronto-temporal 3-4 cm intraparenchymal hemorrhage with left to right shift. The patient soon exhibited decreased responsiveness with a left fixed and dilated pupil. The patient was intubated and given Mannitol with equalization of the pupils bilaterally. The patient was then taken to the OR where the clot was removed. The patient received multiple units of platelets, red blood cells and fresh frozen plasma. The patient's initial postoperative exam showed the pupils to be 2 mm bilaterally but non-reactive with intact doll's eyes, corneal, and gag reflexes. She had purposeful movement of her left upper extremity but extensor posturing of her right upper extremity. She had flexion withdrawal in both lower extremities. She was therefore hyperventilated, sedated and pharmacologically paralyzed. Later that evening the patient's left pupil again dilated and became non-reactive. A repeat CT scan was done which showed a larger area of hemorrhagic tissue in the same area with a large midline shift. The sedation and paralytic agent were discontinued; however the patient continued to demonstrate no evidence of neurological function. A bone marrow biopsy was performed which showed acute 'leukemia. A cerebral blood flow study demonstrated no effective cerebral perfusion. An apnea test was performed which demonstrated no respiratory drive. The patient was therefore declared brain dead and disconnected from the ventilator and the patient passed away shortly thereafter. ---- At autopsy the brain weighed 1450 grams. Multiple hemorrhages were discovered including the left frontal lobe, left cerebellar hemisphere, with intraventricular and subarachnoid extension. There was evidence of uncal, cingulate and tonsillar herniation.
