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Washington University Experience | VASCULAR | Infarct - (Pseudo) Laminar necrosis | 4A0 Case 4 History
Case 4 History ---- The patient was a 44 year-old woman with a history of hypertension who presented to the BJH emergency department (ED) in October 2004 with headache and altered mental status. On initial exam in the ED she was alert, oriented, and following commands. BP was elevated to 220/110. Head CT showed subarachnoid blood in the basilar cisterns and a subdural hematoma (SDH), most pronounced over the left tentorium. In the ED the patient had a witnessed seizure with decline in her mental status and extension of the SDH on repeat CT. She was admitted to neurosurgery. Cerebral angiography revealed 6 aneurysms involving portions of the circle of Willis. The largest measured 1x1.5 cm and was located at the origin of the left posterior communicating artery, which was the suspected source of bleeding. Other aneurysms were located on the left anterior choroidal artery, left internal carotid artery terminus, right MCA bifurcation, right posterior communicating artery and right pericallosal artery. Following the seizure, the patient was unresponsive with a fixed and dilated left pupil. She therefore underwent emergent left frontotemporal craniotomy, evacuation of the underlying hematoma, and clipping of 3 of the aneurysms including the left posterior communicating artery. An intracranial pressure monitor was placed. The following day she returned to the OR for decompressive left fronto-temporo-parietal craniotomy. She was transferred to a skilled nursing facility; however, the following day the patient was readmitted from the nursing facility for fever. Blood cultures again showed coagulase negative staph of questionable significance. Head CT revealed infarcted tissue herniating through the left fronto-parieto-temporal craniotomy defect. The patient became progressively more bradycardic during this admission. On 12/20/04 the patient was found unresponsive with pulseless electrical activity. Resuscitation efforts were unsuccessful.
