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Washington University Experience | VASCULAR | Infarct, watershed | 1A0 Case 1 History
Case 1 History ---- The patient was a 64 year old man with a long history of hypertension and prediabetic labs with increased cholesterol and triglycerides. Workup with a new physician included an EKG which showed a “silent” MI. A stress test lead to cardiac catheterization and the demonstration of severe stenosis of multiple large coronary vessels. Surgery (bypass x 4 vessels) was performed despite lack of symptomatology. Following surgery on December 20th, the patient was unarousable and without response to pain. The intraoperative course had been unremarkable but with frequent VPCs and one short run of ventricular tachycardia noted during surgery. Neurologic examination after surgery showed full doll's eyes reflexes, pupils 1.5 mm. which reacted sluggishly to light. The fundi showed no papilledema. Tendon jerks were absent and both toes went up. With painful stimuli the patient made slight movements. There was no abnormal posturing. Cheyne-Stokes respirations were noted. A CT scan showed areas of decreased density along the ACA/MCA and MCA/PCA vascular watershed bilaterally. EEG demonstrated diffuse delta and theta slowing. On January 18 the patient was found pulseless without respirations. It has never been determined precisely what happened during surgery or shortly thereafter to definitively explain the patient’s clinical course. ---- At the time of autopsy the circle of Willis was intact, classically constituted and symmetrical with only mild atherosclerosis. The external surfaces of the cerebellum showed areas of cystic encephalomalacia on the superior surface in the watershed distribution between the superior and posterior inferior cerebellar arteries. There was a hemorrhagic infarct involving the right caudate nucleus (another watershed region). The lungs showed pulmonary edema and bronchopneumonia.
