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Washington University Experience | VASCULAR | Herniation, tonsillar | 9A0 Case 9 History
Case 9 History ---- This 40 year old male with a history of Type I diabetes mellitus and multiple admissions for diabetic ketoacidosis, peripheral vascular disease with recurrent lower extremity infections including osteomyelitis status post below knee amputation in June 2006, chronic kidney disease, chronic diarrhea, and non-ischemic cardiomyopathy. On June 30th, he presented to the BJH ER for evaluation of extremity pain and shortness of breath. In the emergency room his arterial blood gas pH was 6.99 with pCO2 of 26. He was found to have a serum potassium value of 8.3 and a serum creatinine value of 13.4. He was hypotensive. He was intubated and admitted to the ICU for further management of presumed sepsis. He was started on broad spectrum antibiotics. He received hemodialysis. On July 2nd, he was described as being unresponsive with asymmetric, non-reactive pupils on no sedation. A head CT showed diffuse severe cerebral edema with effacement of the basal cisterns and fourth ventricle. Neurologic examination demonstrated loss of brainstem. The patient did not respond to painful stimuli. Reflexes were diffusely absent. Repeat head computerized tomography was obtained on July 3rd, 2008 and demonstrated no change in the diffuse severe cerebral edema with complete effacement of the sulci and basilar cisterns. Early on July 5th, 2008, the patient experienced a sudden decrease in blood pressure and increase in heart rate. Later that morning the patient was found pulseless and breathless and passed away. ---- At autopsy his unfixed brain weighed 1320 grams. Pathological examination of this patient's nervous system showed evidence of severe global acute hypoxic/ischemic changes with marked edema and uncal and tonsillar herniation as well as secondary brainstem (Duret) hemorrhages.
