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Washington University Experience | VASCULAR | Herniation - Cingulate | 3A0 Case 3 History
Case 3 History ---- The patient was a 48 year old man with history of chronic ETOH abuse who was drinking with his family on 07/04 and was not feeling well. His fiancé assisted him to his room to rest and left. Upon her return, she found him unresponsive and with dried blood around his mouth. There was no history of a fall. The patient was unresponsive to painful stimuli, and had no gag or corneal reflexes in the ED with a Glasgow Coma Scale of 3 and a core temperature of 30.4oC. A head CT at ED showed extensive intraparenchymal hemorrhage involving the left frontal and bilateral parietal regions extending into lateral ventricles with mild hydrocephalus. CT also noted a left to right subfalcine herniation as well as a left uncal herniation. Diffuse, bilateral subdural and subarachnoid hematomas were also identified in the absence of skull fracture. The patient was coagulopathic with an INR of 2.07 and thrombocytopenic (platelet 56K). His blood ETOH was 192 mg/dl. Urine toxicology was negative. A neurologic exam showed unreactive pupils with no corneal reflex, dolls eye movement, and response only to obnoxious stimuli. The patient subsequently developed progressive tachycardia with dropping blood pressure and finally became pulseless. His family decided to withdraw CPR and he expired on 07/04. ---- At autopsy the unfixed brain weight was 1130g. There was extensive hemorrhage and edema originating in the left striatum, likely hypertensive in origin, with extension to left frontal, temporal, occipital lobes, thalamus, left and right lateral ventricles. Hypoxia/ischemia ranged from selective neuronal necrosis to infarction in the cerebral cortex, basal ganglia, thalamus and cerebellum. There was evidence of left uncal and cingulate herniation, as well as midbrain compression (Duret) hemorrhages
