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Washington University Experience | VASCULAR | Infarct - Acute | 5A0 Case 5 History
Case 5 History ---- The decedent was a 45 year old man with right lung adenocarcinoma, diffusely metastatic to bone and liver, malignant pleural effusion status post pleurocentesis, deep vein thrombosis status IVC filter on lovenox. In May 2015, he underwent 4 cycles of carboplatin/pemetrexed with no complications. He was admitted again on 9/4 with chest pain, dyspnea and back pain. Troponin was 0.19 but symptoms resolved spontaneously and EKG was consistently normal. Therefore, his pain was attributed to known pulmonary embolism and troponin leak attributed to demand ischemia. He was maintained on home lovenox. He was admitted again on 9/15 with sudden onset of severe back pain. A spine CT demonstrated diffuse osseous metastases with compression fractures at T9/L1. CXR demonstrated new peripheral airspace opacities. Lovenox was stopped on the night of 9/16 and he was scheduled for vertebroplasty on 9/17, when he had acute onset of dysarthria, right gaze deviation and left sided weakness. Head CT showed complete right hemispheric stroke, edema and possible herniation. He was outside the tPA window, so thrombectomy was attempted but the clot still remained after 5 attempts. He was then sent to the ICU and ultimately made comfort care after discussion with his family. He was pronounced dead on 9/19. ---- At autopsy the unfixed brain weighed 1340g. A thrombus was demonstrated in the right middle cerebral artery including the origin of the lenticulostriate arteries with acute infarction of much of the right hemisphere and the basal ganglia. There was grooving of the unci, particularly on the right side, which appeared to reflect incipient uncal herniation.
