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Washington University Experience | VASCULAR | Infarct - (Pseudo) Laminar necrosis | 2A0 Case 2 History
Case 2 History ---- The patient was a 44 year old woman who was found unconscious in her burning house in December 2004. Emergency Medical Technicians found her pulseless and initiated CPR. She was estimated to have been pulseless for 5-10 minutes. Emergent tracheostomy was placed because bronchoscopy revealed dense soot and edema. Initial arterial blood gas revealed pH 7.18, pCO2 21, carboxyhemoglobin 32.7% (approximately 10 times normal), and methemoglobin 2.1%. Ethanol level was 297. She had second and third degree burns over 20% of her body surface area which were debrided and eventually skin grafted. Head CT on hospital day 1 showed normal grey-white differentiation and no midline shift or mass effect. The patient remained unresponsive. MRI of the brain was obtained in mid-December 2004, which showed restricted diffusion involving the cerebral cortex (primarily gray matter) in the middle and posterior cerebral artery distributions bilaterally, with relative sparing of the anterior cerebral artery distributions and part of the left MCA territory. There was corresponding low signal on the ADC map consistent with hypoxic/ischemic injury. There was no FLAIR or T2 signal abnormality. The affected regions showed leptomeningeal enhancement. No infratentorial ischemia was seen. Neurologic exam in mid-December 2004 revealed spontaneous respirations, intact gag reflex, and no movement of extremities in response to noxious stimuli. Repeat brain MRI approximately one week later showed resolution of the abnormal diffusion restriction involving the cerebral cortex, but interval development of increased diffusion involving the periventricular white matter, corpus callosum, and basal ganglia, with corresponding low signal on the ADC map, consistent with hypoxia/ischemia. She continued to have intact gag reflex and no response to pain in her extremities. Her clinical course was subsequently complicated by sepsis with hypotension requiring pressors. A chest tube was placed for right sided pneumothorax. Head CT showed focal areas of high attenuation within the basal ganglia, most notably the bilateral globus pallidus. There was also diffuse, symmetric loss of gray/white differentiation in the cerebral cortex, with focal sparing of some gyri that manifested as relative hyperattenuation. There was no mass effect, midline shift, hydrocephalus, or uncal herniation. Her prognosis for neurologic recovery was felt to be extremely poor. After extensive discussion with the family and ethics staff, do not resuscitate status was implemented. She developed empyema with purulent drainage from the chest tube. Ventilatory support was weaned and she was transferred out of the intensive care unit and expired.
