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Washington University Experience | VASCULAR | Herniation, uncal | 12A0 Case 12 History
Case 12 History ---- This patient is an 81 year-old woman with depression, back pain, hypertension, hypothyroidism, and a vague history of two prior strokes which consisted of right hand weakness and “visual problems”, three and one years prior to admission. She had no residual deficits. Other medical history included cholecystectomy, partial colectomy to remove a fish bone and right hip replacement. She lived independently, had no history of cardiac disease, and she took no medications except pain medications and Remeron. On 7/22 she developed sudden chest pain, followed by a ventricular fibrillation arrest in the ambulance, treated with one shock. She had an emergent cardiac catheterization and had multiple coronary stents placed. She received IV heparin and Integrilin during the catheterization, and she was started on aspirin and Plavix. Following the procedure, she had an episode of symptomatic bradycardia, with heart rate of 26, systolic blood pressure of 80, and poor responsiveness. She improved with a dopamine infusion. On 7/23 she was noted to have right hemiparesis and aphasia. A head CT showed hypodensities in the right cerebellar and left parietal areas. MRI could not be performed due to recent stenting. That evening at 20:40, she was found on the floor with a “golf-ball sized hematoma” above the right eye. At 22:00, her heart rate dropped from the 90’s to 20’s, and systolic blood pressure increased from 150 to 250s. She had absent corneal and papillary reflexes, but did have cough and “some movements”. Another head CT showed an acute large right subdural hematoma with 2 cm of midline shift. She was intubated, hyperventilated, given mannitol and atropine (for bradycardia), and transferred to BJH. Neurosurgery evaluation determination was that a surgical procedure was not indicated. Based on her previously stated wishes and poor prognosis, she was extubated and died. ---- Autopsy showed a large right subdural hematoma and subgaleal hemorrhage (traumatic in origin) and multiple parietal hemorrhages. The patient’s coagulopathy likely contributed to the severity of the hemorrhages.
