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Washington University Experience | VASCULAR | Herniation - Cingulate | 2A0 Case 2 History
Case 2 History ---- The patient was a 64 year old man with history of pulmonary emboli with IVC filter placement, COPD, coronary artery disease and a history of heavy smoking, who presented on 12/17 with lower extremity edema and intermittent epistaxis, worsening orthopnea for 2 weeks, dyspnea on exertion, productive cough for 20 days, sweats and chills. He had a hemodynamically significant pericardial effusion and pericardiocentesis (12/21) produced 700ml of serous fluid which was positive for adenocarcinoma. He then developed acute renal failure and Heparin-induced thrombocytopenia (HIT). A pericardial window was created on 12/24. On lower extremity Doppler exam, he was found to have deep venous thrombi bilaterally. On 12/31 he required IV tissue plasminogen activator injection for lysis of an IVC filter thrombus. Immediately after the procedure he had a left fixed dilated pupil and was unresponsive. A head CT showed a left temporal intraparenchymal hemorrhage and a large acute left subdural hematoma with left subfalcine and uncal herniation. A follow up neurological exam the same day reported that the patient didn’t open his eyes, regard or follow commands. His pupils were 4 and 8 mm, non-reactive, with negative corneal reflexes, positive dolls, with extensor posturing to deep stimuli. After discussion with the family about prognosis, his level of care was changed to comfort measures only on 1/01. He was found pulseless without breath sounds 2 days later and pronounced deceased. ---- An autopsy showed an unfixed brain weighing 1430g. Most significant was a recent hemorrhagic infarct involving the left frontal, parietal, temporal, and occipital lobes and cerebral peduncle with extensive left subdural and subarachnoid hemorrhages and edema. There was evidence of subfalcine herniation of left cingulate gyrus and left uncal herniation with midbrain Duret hemorrhages. It was thought that this coagulopathic patient developed a large subdural and left temporal lobe hemorrhage following intravenous tissue plasminogen activator treatment resulting in left uncal and cingulate herniation. Subsequently, reperfusion resulted in hemorrhagic infarction involving the left anterior, middle and posterior cerebral artery territories.
