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Washington University Experience | VASCULAR | Infarct - (Pseudo) Laminar necrosis | 6A0 Case 6 History
Case 6 History ---- This was a 73 year old man with a history of several myocardial infarctions the last recently in September 1978. In addition, in January of 1979 a lobectomy was performed for resection of epidermoid lung carcinoma. On 1/20/80 he noticed inability to get out of bed partly because of left hand and leg weakness. He also had slurred speech and numbness on the left hand and leg. He denied chronic alcohol ingestion but admitted to five cigarette packs a day. His speech was slurred but not aphasic. A right gaze preference was detected and a questionably left-sided visual field cut was noted. Pinprick was said to be decreased on the left side of his face but the corneal reflexes were normal. The chest x-ray showed cardiomegaly and a left pleural effusion. The patient quickly developed respiratory failure and was intubated. He also became hypotensive but that was responsive to Dopamine drip. At the end of that emergency treatment it was noted that he continued to have purposeful movements on the right and that he would answer questions appropriately with head nods and right hand squeezes. It was subsequently shown that the left leg was mottled, cold and without a femoral pulse. Impression that he had an embolism in the left iliac system. A femoral embolectomy was done under general anesthesia and a significant thrombus was removed. A CT scan of the brain showed two lucent areas, one in the right parietal region and another in the internal capsule on the right. A repeat CT scan showed no evidence of an intracranial bleed to count for the acute onset of seizures. He continued to improve slowly for several days but two weeks later he suffered an acute cardiorespiratory arrest. An EKG showed a new right bundle branch block. After he recuperated from the arrest, mottling of the right leg was noted and the leg was warmed. However, he remained unresponsive. Doll's eyes remained present. Tone was increased throughout. No reflexes were elicited. Off the respirator, roving eye movements were noted. He also had some response to physiologic stimuli such as name calling with a concomitant increase in low amplitude high frequencies. ·This was thought to be suggestive of a locked in state. He passed away shortly thereafter. Multiple infarcts in different vascular territories suggested an embolic origin but no definitive sources were identified.
