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Washington University Experience | VASCULAR | Infarct - Hemorrhagic | 16A0 Case 16 History
Case 16 History ---- This 83 year old woman was admitted with the sudden onset of global aphasia and right hemiparesis. The patient had a history of hypothyroidism, congestive heart failure, and chronic atrial fibrillation. She was apparently in her usual state of health when she was talking to her sister-in-law on the phone and she suddenly became unresponsive. She was brought to the ER with Cheyne-Stokes respirations, BP 145/85, pulse 120 and irregular, and was afebrile. Her general exam was remarkable for a small ecchymosis on her right forehead and signs of moderate congestive heart failure in the form of increased jugular venous pulsation pressure, bibasilar crackles in the lungs, l+ pitting edema in both legs, and a 2 out of 6 holosystolic murmur at the apex and axilla. Neurological exam was remarkable for global aphasia, yet the patient was awake. She had a left gaze preference, no response to visual threat in any field, full oculocephalics, slight decrease in .the right corneal reflex, a flattened right nasal labial fold. Gag reflex was present. The patient was seen to move the left extremities purposefully to sternal rub but did not move either in response to stimulation or spontaneously the right arm and leg. The right upper extremity was flaccid. The right leg was slightly spastic. The reflexes were 3+ in the upper extremities and at the knees, absent at the ankles, and there were bilateral Babinski signs. EKG showed atrial fibrillation. A CT scan on the day of admission, 7/26, showed only cortical atrophy and slightly enlarged ventricles commensurate with this and no signs of blood. ---- The patient was admitted to the neurology service with the admitting diagnosis of probable left cerebral and possible bilateral embolic infarction, most likely from a cardiac embolic source. The patient was anticoagulated with heparin and her congestive failure treated with diuretic and digoxin. On the second day of her hospitalization there was no change in her neurological status but the heparin had to be discontinued because of enlarging hematoma of the right lower leg. On that day she was also hypotensive at BP of 100/60 most likely on a volume depletion basis. Therefore, increased fluids were given to the patient. There was amelioration of her congestive heart failure, however there was no improvement or significant change in her neurological exam until hospital day #6. The patient then developed a dilated left pupil with both eyes unresponsive to light. It was felt that the patient was having cerebral herniation, secondary to edema from a huge left cerebral infarction. Because of the patient's age, medical problems and poor prognosis for functional neurological recovery, the patient was “no code”. The following day the patient was found without a blood pressure, ---- At autopsy a large left hemorrhagic MCA infarct was identified with histologic features of approximately 1 week duration as well as bilateral edema. Several factors in this case favor an embolic event including sudden onset, lack of intracranial atherosclerosis, the hemorrhagic nature of the infarct, and the presence of a splenic infarct, possibly indicating systemic emboli. However, no source for emboli was found at autopsy. ---- She had Duret hemorrhages and uncal herniation.
