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Washington University Experience | VASCULAR | Infarct - (Pseudo) Laminar necrosis | 1A0 Case 1 History
1A0 Case 1 History ---- The patient was a 59-year-old man with a history of diffuse large B-cell lymphoma (status post R-ICE and CHOP chemotherapy and autologous stem cell transplant 3 years prior), hypertension, diabetes, hyperlipidemia, and a stroke in October of 2011 (MRI evidence of right PCA and left parietal lobe infarcts) with residual left-sided weakness. Carotid scan in March 2012 showed 80-99% stenosis in the left mid internal carotid artery and no flow in the right carotid artery. In August, 2012 the patient presented with a new onset seizure following a fall without loss of consciousness. Later he was unresponsive and was taken to the ED where he was noted to have rightward eye deviation, rhythmic shaking of his head to the right and right lower extremity jerking. He received Ativan in the ambulance and again in the ED and his eye deviation and generalized shaking resolved. He was then admitted to the Neurology ICU for status epilepticus but no seizures were noted on EEG even with non-rhythmic jerking of left upper extremity. The patient was extubated and doing well in late August when an MRI showed numerous supratentorial, enhancing hyperintensities; the differential diagnosis was consistent with a CNS lymphoma vs. vasculitis vs TB/autoimmune etiology. CSF cultures were negative. The patient was stable and moved to the floor but 30 minutes later he started decompensating and not answering questions. He also became diaphoretic, tachycardic, and tachypneic. A head CT showed interval development of a large intraparenchymal hematoma with resultant subfalcine herniation and likely right uncal herniation. Due to the fact that the patient remained unresponsive after the hemorrhage the family decided to make him comfort care and discontinue further intervention.
