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Washington University Experience | VASCULAR | Infarct - Embolic | 13A0 Case 13 History
Case 13 History ---- The decedent was a 57-year-old woman with a history of hypertension, hyperlipidemia, and depression who experienced symptoms of bilateral blurry vision, unsteady gait, and left facial numbness starting on 07/04. A head CT at an outside hospital on 07/10 showed only chronic small vessel ischemic disease. She presented on 07/14 to BJH ED with worsening weakness, altered mental status, vision loss, and headache. A head CT showed cytotoxic edema involving bilateral occipital lobes, cerebelli, and possibly the left frontal lobe with superimposed petechial hemorrhage in the left occipital lobe. A subsequent brain MRI showed multiple acute to subacute cortical and subcortical infarcts in the watershed regions and infarcts in the bilateral basal ganglia and cerebellum. She was also found to have an NSTEMI with a troponin of 7.1. For this, she was started on metoprolol and atorvastatin. Around midnight of 07/17, she awoke with worsening shortness of breath with oxygen saturation in the 80s that ultimately required intubation. EKG showed ST elevation myocardial infarction. Emergent left heart catheterization with recanalization and stent placement of the distal right coronary artery was unsuccessful since the artery was rapidly re-occluded, and the procedure was stopped without stent placement. She developed critical limb ischemia on 07/18 requiring a right forearm fasciotomy and thrombectomy of the right brachial artery. A chest CT showed multifocal wedge-shaped defects in the kidneys, spleen, and lungs and acute pulmonary emboli thought to be the result of marantic endocarditis from an underlying lung malignancy (a hypercoagulability workup was negative). A transthoracic echo on 07/19 was significant for mitral valve vegetations. The patient developed multi-organ system failure with acute renal failure and shock liver. The decision was made to transition to comfort care, and she expired on 07/29. ---- Autopsy showed multifocal thromboembolic infarcts with thromboemboli, largely subacute, involving the frontal, parietal, and occipital lobes, thalamus, and cerebellum. Although the presence of multiple thromboemboli would not be expected in watershed infarcts, it is likely that the autopsy CNS findings involve both hypoperfusion, complex rheologic changes and thromboembolism.
