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Washington University Experience | VASCULAR | Infarct - (Pseudo) Laminar necrosis | 7A0 Case 7 History
Case 7 History ---- The patient was a 45 year old right handed female in good health until age 29, when she was found semi -conscious with dysarthria. She was hospitalized for a "nervous breakdown'', and returned to her baseline. Two years later she had a similar episode with severe headaches. Workup showed a 12 mm circular calcification in the anterior region of the right middle cerebral artery. There was also lucency in the right frontal lobes suggesting previous infarction. Cerebral angiography was performed, revealing a large intracranial aneurysm at the neck of the right middle cerebral artery, a second 1-cm diameter aneurysm at the origin of the right posterior communicating artery, a 2-cm multi-lobulated aneurysm at the tip of the basilar artery, and another aneurysm was seen at the bifurcation of the left middle cerebral artery. She apparently collapsed at home and was resuscitated her until she gradually developed gasping respirations. She was otherwise unresponsive. The patient had a partial left 3rd nerve palsy. Visual fields were full. Sensation, motor strength, and coordination were normal. The patient was diffusely hyperreflexic with clonus of the ankles with bilateral Babinski's. Head and CT scan revealed blood along the falx consistent with subarachnoid hemorrhage. Lumbar puncture showed grossly bloody CSF with an opening pressure of 310 mm. The patient was treated with Dilantin, Amicar, sedation and steroids. Mental status gradually improved over the next few days. On 10/23 the patient underwent repeat cerebral angiography. Multiple aneurysms were as previously described except for a change in the right internal carotid aneurysm which was felt to be the aneurysm that had bled. Mild diffuse spasm was seen both in the anterior and posterior circulation. Two days post angiogram the patient became considerably more lethargic with a persistent increase intracranial pressure resulting in the placement of a ventriculostomy. On 11/1 a frontal craniectomy was performed with clipping of the right internal carotid aneurysm. Post-operatively the patient had a mild to moderate left hemiparesis which resolved over the next week. She was intermittently lethargic and disoriented. Ten days post-operation, the patient suddenly deteriorated. At that time she was comatose with deep slow respirations. Ice water calorics were negative. Gag reflex was present. The patient was bilaterally decerebrate to deep pain with bilateral clonus and Babinski reflexes. Head and CT scan revealed marked edema of the right hemisphere with right to left shift and obliteration of the right lateral ventricle. On 11/12 the patient had no spontaneous respiration and was maintained on the ventilator. She remained in this state until death two weeks later.
