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Washington University Experience | VASCULAR | Herniation, uncal | 1A0 Case 1 History
Case 1 History ---- This 60 year old man was admitted on 7/23 because of intermittent “hazy” feelings, following six months of headaches and the recent discovery of ischemic changes in the right optic disc. His prior medical history included hypertension and a coronary artery bypass with good results. His examination at the time of his admission was normal except for bilateral carotid bruits and neovascularization of his right optic disc without any retinal lesions. On 7/24 he underwent right carotid arteriography which showed 65% narrowing of the proximal internal carotid artery with ulceration. During attempted catheterization of the left common carotid, but prior to actually getting the guidewire into the artery, the patient suddenly became aphasic with right hemiplegia. Left carotid arteriogram by direct neck approach was performed next which showed ulcerated plaque in the proximal left internal carotid artery and occlusion of the left middle cerebral artery 1-2 cm distal to its origin. The patient went to surgery for emergent embolectomy of the left middle carotid artery. The specimen removed was a cylindrical tissue fragment ~0.4 cm composed of unremarkable thrombus. Postoperatively, the patient had right hemiplegia and global aphasia. The next morning the patient was more lethargic and his left pupil became fixed and dilated. He was then electively intubated and continued on Decadron. Repeat CT scan of his head showed left cerebral swelling with left to right shift and no clots. By that evening he was comatose and his only response to pain was decerebrate posturing. At this point neither pupil reacted to light, with the left pupil larger than the right. By 7/26 he began to lose all extraocular movements which was complete by the next day. On 7/29 he became febrile to 38.8oC. Routine cultures were obtained and on 7/30 he was found without pulse or EKG activity. ---- Autopsy showed the left middle cerebral artery and adjacent areas of internal carotid had at most focal 25% occlusion by atherosclerosis and no residual thrombus, even at the surgical site, or at the level of MCA trifurcation distally.
