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Washington University Experience | VASCULAR | Infarct, watershed | 8A0 Case 8 History
Case 8 History ---- The patient was 56-year-old female with past medical history significant for celiac disease, Herpes zoster, COPD, chronic hyponatremia thought to be secondary to malabsorption, and hypothyroidism who presents for altered mental status with head CT concerning for Reversible Posterior Leukoencephalopathy Syndrome (RPLE). The patient on 06/19/2012 arrived oriented x3 and speaking coherently with a three week headache and thought her medications were causing it. She received saline, Toradol, Benadryl, and Reglan. Head CT was negative at that time. On 06/22 and 6/23 she presented again with headaches. She received Phenergan and Toradol. On 06/23/2012 she presented again with headache and altered mental status was noted per family. The patient received Toradol, Decadron, Nubain, Phenergan, and Ultram and was given prescriptions for Prednisone, Ultram, and Phenergan. On 06/24/2012 the patient was confused, irritable, sleepy, and responded to verbal stimulation with agitation. Head CT was again concerning for RPLE. She received IV fluids and was transferred to BJH. Notably, the patient had fluctuation of her blood pressure on 06/19/2012 with lows of 143/86 mmHg and as high as 192/92 mmHg. ---- Chronic hyponatremia was thought to be secondary to malabsorption with recently diagnosed helicobacter pylori. MRI on 6/25/2012 showed large areas of T2/FLAIR hyperintensity and diffusion restriction in the parietal and occipital lobes bilaterally as well as in the right cerebellar hemisphere, the centrum semiovale on the right greater than on the left, in the inferior left frontal lobe, in the thalami bilaterally, and in the splenium of the corpus callosum. Given the extensive restricted diffusion and the location of several of these areas in a watershed distributions, these changes were favored to represent infarction, possibly from hypotension or severe shifts in blood pressure. Effacement of the suprasellar cisterns were consistent with uncal herniation and the patient expired.
