Table of Contents
Washington University Experience | VASCULAR | Infarct - Hemorrhagic | 12A0 Case 12 History
Case 12 History ---- The patient was a 53 year-old man with a past medical history of systemic amyloidosis and Hodgkin's lymphoma status post XRT in the 1970s, as well as hypertension, who had significant stenosis of the neck vasculature and airway as a result of remote radiation therapy. He presented to BJH on 06/18 for a vascular surgery procedure to decompress left-sided thoracic outlet syndrome as well as to have left subclavian-to-axillary bypass. The procedure involved clamping the left vertebral artery for 31 minutes and occurred on 6/1. Postoperatively he was dysarthric and had double vision with dysconjugate gaze. His initial neurologic exam was consistent with brainstem strokes and head CT done immediately showed a relatively large left cerebellar infarct, as well as infarct involving the right cerebellum and brainstem. He was transferred to the NICU for observation and continued care. He received a Neuro interventional angiogram, which demonstrated chronic right-sided common carotid occlusion as well as a left external carotid occlusion. There was a thrombus in the distal third of the basilar artery. On 06/24 it was noted that the patient had a dilated right pupil, but was following commands. At that point a repeat MRI/MRA was performed which revealed new infarcts in bilateral thalami, right midbrain, hypothalamus and right occipital hemisphere with no extension of known basilar tip thrombus. The patient developed fever in the NICU thought to be due to Pseudomonas tracheitis. At this time, the patient's platelets also began to rise reaching a maximum of 14,000. In addition, the patient developed coffee ground emesis while an esophagogastroduodenoscopy revealed trace erosions of the mucosa with no active bleeding. The remainder of the patient's hospital stay was complicated by respiratory failure. A chest tube was inserted for a large left pleural effusion and the patient was started on levophed for pressor support. The patient subsequently lost pulse and was coded for cardiac arrest. The patient did not regain a pulse in spite of code medications. He expired 07/30. ---- At autopsy the weight of the unfixed brain was 1410g. There were, subacute and remote cerebral infarcts involving right frontal lobe, bilateral thalami, bilateral cerebellum, midbrain, and pons. His sudden demise was apparently due to a large saddle pulmonary embolus. In contrast, the presence of multiple subacute to remote cerebral infarcts most likely reflects prior thrombo-embolic disease. The patient was at increased risk for the latter based on his known cervical and thoracic vascular disease, as well as potential mechanical and coagulopathic changes associated with his operation and the mesothelioma that was identified at general autopsy.
