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Washington University Experience | VASCULAR | Infarct - Hemorrhagic | 2A0 Case 2 History
Case 2 History ---- The patient was a 26 year old woman who was admitted to an OSH on 7/21 with a 3 day history of episodic nausea and vomiting followed by diarrhea and severe frontal headache. The episodes started about 1. 5 months prior to admission. Her blood pressure in the ER was 258/140 mmHg. Her past medical history reveals type 2 diabetes for 10 years (including retinopathy with photo-coagulation, diabetic ketoacidosis), hypertension for 2 years, peripheral vascular disease and chronic renal failure treated with dialysis. The patient was a 10 pack-year smoker. She has a 1.5 year old child. On 7/24 she complained of headache and appeared hypersomnolent. She was transferred to BJH, a CT was performed and showed a subarachnoid hemorrhage [Fischer Grade II (>1mm)] which filled the basal cisterns as well as the Sylvian fissure bilaterally clinically thought to have a hypertensive etiology. Shortly after the CT-scan, she had a bradycardic and hypotensive event. On the 7/25 she had non-reactive pupils, absent corneal reflexes, absence of oculocephalic reflex, no gag/cough reflex and did not respond to noxious stimuli. Following the apnea test she was pronounced brain dead on July 25th. ---- At autopsy the unfixed brain weighs 1410g. A hemorrhagic infarct involved the cerebellum and multiple territories of basilar and PCA with superimposed tonsillar herniation. Histologically, the lesions all appeared similar in age and all appeared to be hemorrhagic infarcts, likely all resulting from her 1 day event beginning on 7/24. Considering the CT subarachnoid hemorrhage, there was no evidence of a vascular malformation, aneurysm or traumatic history. It is not completely clear what the exact sequence of events was in this patient. Nonetheless, coupling the edematous swollen cerebellar hemispheres, tonsillar necrosis and herniation, complex changes in blood flow in the posterior fossa may have resulted in the patterns of ischemic damage.