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Washington University Experience | VASCULAR | Infarct - Lacunar | 2A0 Case 2 History
Case 2 History ---- The patient is a 64-year-old man with a history of coronary artery disease status post drug eluting stent, diabetes mellitus, medication non-compliance and stroke x 2 with residua of cognitive impairment, dysarthria, and right hemiparesis who presented to the BJH ER on 12/9 unresponsive, hypotensive to 85/54, hyperglycemic (1,470 on BMP) and hypothermic to 33.6oC. He had last been seen at his baseline by family members 8 hours prior to presentation to the ER. Workup in the ER revealed a troponin elevation, diabetic ketoacidosis, acute renal failure, leukocytosis (15,100) and hyperkalemia (6.9). The patient was bolused with IVF, received calcium gluconate, and was started on insulin and heparin with persistently elevated blood sugars despite upward titration of his insulin. His non-contrast head CT in the ER revealed no acute pathology but was remarkable for old bilateral lacunar infarcts in the right basal ganglia and left internal capsule and periventricular white matter changes consistent with microvascular disease. He remained unresponsive and was subsequently admitted to the MICU. His urinalysis was consistent with a UTI and his blood cultures grew Proteus mirabilis. He had an HbA1c of 8.1 and hypernatremia which was slowly corrected. He remained unresponsive. Pupils were equal round and reactive, positive corneal and gag reflexes were present, left hemiparesis and diffuse hyperreflexia. His exam remained unchanged for the duration of his hospitalization. Brain MRI revealed widespread patchy T1 and T2 signal abnormalities involving cerebral gray and white matter, cerebellum, midbrain, and pons. The DDx included an infectious/inflammatory or a metabolic process and less likely secondary to multifocal infarcts. CSF revealed a protein of 98, glucose of 151 with serum of 373, 5 total cells which were all nucleated (27% PMN, 19% L, 11% Mono, 43% Macro) and unremarkable culture and PCR data with no evidence of malignancy on cytologic examination. The family decided to make the patient comfort care and he passed away. ---- At autopsy the weight of the unfixed brain was 1240 grams. The microvasculature in the gray and white matter is markedly hyalinized without vasculitis or amyloid. A history of hypertension, diabetes and coronary artery disease resulted in marked atherosclerosis and arteriolosclerosis. There are a few watershed infarcts as well.
