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Washington University Experience | VASCULAR | Infarct - Embolic | 16A0 Case 16 History
Case 16 History ---- The patient was a 44 year old obese woman with diabetes, poorly controlled hypertension, hyperlipidemia and chronic kidney disease. On 12/3 the patient presented to BJH hospital with progressive dyspnea and worsening peripheral edema for 5 days. At that time, her blood gas showed pH of 7.31, pCO2 of 37, pO2 of 90, bicarb of 19, with FiO2 of 50%. Chest CT showed diffuse pulmonary edema. Her blood pressure was 234/147, she was found to have congestive heart failure with elevated BNP of 2096, elevated troponin level, acute and chronic kidney disease, and uncontrolled diabetes. She was started on antibiotics for possible community acquired pneumonia, diuretics for congestive heart failure and pulmonary hypertension, and was anticoagulated for possible pulmonary embolism. The patient deteriorated and was intubated on 12/6. Later, she developed weakness and a CT scan on 12/7 revealed left middle cerebral artery ischemic stroke. The patient also developed acute respiratory distress syndrome. On 12/9 another brain CT scan showed interval increase in substantial cerebral edema involving the left cerebral hemispheric and, to a lesser degree, the right cerebral hemisphere, predominantly the temporal and parietal lobes, suggestive of new areas of infarction. On 12/10 the family decided to withdraw care due to her poor neurological state, and the patient was extubated. She expired on 12/10. ---- Autopsy findings included thromboemboli involving left internal carotid, MCA and ACA and right MCA with recent extensive infarcts. Microthromboemboli were numerous in left MCA/ACA and, to a lesser degree, right MCA territories consistent with the patient's clinical history of brain infarction ~3 days prior to expiration. Cerebral edema with left to right midline shift and incipient subfalcine herniation were identified.
