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Washington University Experience | VASCULAR | Infarct, watershed | 6A0 Case 6 History
Case 6 History ---- The patient was a 78 year old woman in her usual state of good health until approximately three months prior to admission when she began to note intermittent substernal chest pain with radiation to both arms. One week prior to her BJH admission, EKGs demonstrated extensive STT wave changes consistent with anterior ischemia and possible myocardial infarction. Cardiac catheterization performed on 12/22 demonstrated severe three vessel disease. She was scheduled for coronary artery bypass graft which was delayed due to prolonged bleeding time, thought to be the result of chronic aspirin ingestion, and a complaint of chest pain and acute EKG changes. On 12/27, coronary-artery bypass graft times three was performed. She was unable to be weaned from the bypass, requiring placement of an intra-aortic balloon pump. After returning from the operating room, the patient was found to be unresponsive to verbal and noxious stimuli and to have intermittent clonic movements of the right > left upper extremities. Neurologic examination found her pupils were reactive with a full range of extra-ocular movements. Corneal and gag reflexes and were present bilaterally. Examination of the motor system found all four extremities to be flaccid. Twitching of the fingers of the right hand with progression to the wrist and elbow lasting for 60 seconds was observed, felt to be consistent with focal seizure activity. The clinical impression was of bi-hemispheric infarction, left greater than right, with resultant right focal seizures and multifocal myoclonus. The seizures were treated with Phenobarbital and Dilantin. Unenhanced CT scan 12/31/82 demonstrated multiple bilateral lucencies in the watershed area, compatible with multiple bilateral infarctions. Less convincing lucencies were also noted in the cerebellum as well as moderate cerebral atrophy consistent with age. In spite of adequate seizure control, the patient's level of consciousness did not improve. She developed fever to 39.5 with negative cultures. The patient expired on 1/11.
