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Washington University Experience | VASCULAR | Infarct - Embolic | 21A0 Case 21 History
Case 21 History ---- This patient was a 9 month old infant boy with a history of complex congenital heart disease consisting of tetralogy of Fallot with pulmonary atresia, a ventral septal defect, and multiple aortopulmonary collaterals who had multiple surgeries over his short life. The patient was diagnosed around 3 months of age and, since then, had worsening heart failure and poor weight gain with nasogastric feeding. Unifocalization of aortopulmonary collaterals and placement of a left modified Blalock-Taussig (BT) shunt was performed on 9/18. He subsequently had decreased oxygen saturations in a clinic visit and underwent catheterization to evaluate for BT shunt patency on 10/11. Catheterization identified a stenosis of the proximal collateral vessel serving the left lower lobe of the lung and balloon dilatation times 6 was performed. The patient was then discharged on aspirin and Plavix for anticoagulation. On 10/17, he was transferred to SLCH after his mother noticed that the patient had extremity stiffening and became unresponsive. CT reportedly showed a large, left-sided acute subdural hematoma with an acute left-sided intraparenchymal hematoma, midline shift, and evidence of intracranial hypertension. On the morning of 10/18 he underwent emergent hemicraniectomy for decompression, left subdural hematoma evacuation, and placement of an external ventricular drain. The patient had a lengthy and complex hospital course that was complicated by issues relating to: control of core temperature, mechanical ventilation, sedation, persistent collapse of his right lung, initiation of broad spectrum antibiotics in response to rising white blood cell counts, hypertension, and CSF losses that necessitated replacement with normal saline. When taken off muscle relaxants the patient was noted to have complete right-sided hemiparesis. Subsequent head CT scans (10/31 and 11/5) showed increased size of the left frontotemporal intraparenchymal hemorrhage, with worsening herniation through the craniectomy defect, as well as blood dissecting into the muscle flap. The patient remained in critical condition. On 11/24 his saturations acutely decreased and attempts to restore function failed. Following discussions between the healthcare team and the patient's mother and father, it was decided that support would be withdrawn. The patient was extubated and passed away on 11/24.
