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Washington University Experience | VASCULAR | Infarct - Embolic | 11A0 Case 11 History
Case 11 History ---- The patient was a 75 year old woman with multiple medical problems including chronic obstructive pulmonary disease, sleep apnea, type 2 diabetes, obesity, hypertension, osteoarthritis, chronic renal insufficiency, and chronic microcytic anemia. She had a more than one year history of right sided facial numbness. Her symptoms persisted and on 12/20 a CT scan showed opacification of the right maxillary, ethmoidal and frontal sinuses with extensive bony destruction, highly concerning for a neoplasm. A chest CT on 1/9 showed multiple ground glass opacities throughout both lungs with a radiologic differential diagnosis of an inflammatory process or of multi-focal bronchioalveolar carcinoma. Pre-operative evaluation included a negative dobutamine stress test. On 1/16 she underwent a trans-oral biopsy of the right maxillary sinus mass, showing adenoid cystic carcinoma, grade II/III with focal perineural invasion. On 2/20 she was taken to the operating room for a planned maxillectomy. However, the tumor was found to be invading into the orbit and the maxillectomy was cancelled. Post-operatively, she required re-intubation and admission to the CCU. A maxillofacial CT on 2/22 showed possible extension of the right maxillary tumor to the left inferior maxillary sinus. A chest CT also showed right apical and right lower lobe pulmonary nodules which were suspicious for neoplasm. She started radiation therapy as an outpatient. A head CT on 4/8 showed diffuse sinus opacification consistent with her known adenoid cystic carcinoma. Also seen was low attenuation within the bilateral inferior frontal lobes with concern for tumor extension through the ethmoid sinuses and cribriform plate. A brain MRI on 4/8 also was suspicious for extension of tumor into the anterior cranial fossa. Also seen were scattered bilateral acute or early subacute embolic infarcts (one of which had petechial microhemorrhage). On 4/10 the patient's family changed her code status to "do not resuscitate" and pursued hospice care. She died one day later. ---- At autopsy intradural and intravascular metastatic carcinoma, consistent with adenoid cystic carcinoma had resulted in multifocal subacute infarcts, some of which are secondary to tumor embolism
