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Washington University Experience | VASCULAR | Infarct - Embolic | 7A0 Case 7 History
Case 7 History ---- The patient was a 64 year old male with history of pulmonary emboli in 2007 with IVC filter placement, COPD, coronary artery disease and heavy smoking, who presented on 12/17 for lower extremity edema and intermittent epistaxis, worsening orthopnea for 2 weeks, dyspnea of exertion, productive cough for 20 days, sweats and chills. He had a hemodynamically significant pericardial effusion and pericardiocentesis produced 700ml of serous fluid which was positive for adenocarcinoma. He then developed acute renal failure and thrombocytopenia. A pericardial window was created on 12/24. On lower extremity Doppler exam, he was found to have deep venous thrombi bilaterally. On 12/31 he required IV tissue plasminogen activator injection for lysis of an IVC filter thrombus. Immediately after the procedure he was noted to have a left fixed dilated pupil and unresponsiveness. A head CT showed a large acute left subdural hematoma with subfalcine herniation and left uncal herniation, 1.7cm of midline shift, and left temporal intraparenchymal hemorrhage. A follow up neurological exam the same day reported that the patient didn’t open his eyes, regard or follow commands. His pupils were 4 and 8 mm, non-reactive, with negative corneal reflexes, positive dolls, and extensor posturing to deep stimuli. After discussion with the family about prognosis, his level of care was changed to comfort measures only and he was found pulseless without breath sounds 2 days later. ---- At autopsy histological sections of the cerebral cortices show multiple, multicentric, acute, cortical hemorrhagic infarcts preferentially involving the left anterior, middle and posterior cerebral arteries. Underlying white matter shows infarction and edema but little hemorrhage. Occasional emboli were found associated with the areas of infarction
