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Washington University Experience | VASCULAR | Infarct - Lacunar | 6A0 Case 6 History
Case 6 History ---- The patient was an 83 year old woman who was brought to the ER in an unresponsive state. Her past medical history was positive only for hypertension. About a week prior to admission the family began noticing a decrease in her ability to remember things so that she was leaving faucets on, stoves running, etc. On the day of admission she was brought in being found sitting up, unresponsive in a chair. On neurologic exam the patient was lethargic but could be aroused with stimulation. Cranial nerve exam revealed the pupils to be 2 mm bilaterally reactive to light. Extraocular eye movements revealed a right gaze preference with no left gaze to doll's eyes or to cold calorics in the left ear. The gag was asymmetric being decreased on the right. There was increased tone on the right side and although no drift was apparent she moved the right side more sluggishly than the left. The patient withdrew from pin bilaterally. Plantar reflexes revealed the right toe to go up with equivocal reaction on the left. The impression on admission was that the patient had a probable pontine infarct. Workup included a CT scan which showed no evidence of hemorrhage. Lumbar puncture showed an opening pressure of 235 with a closing pressure of 80. Glucose was 87 and protein was 87. Cell count was 35 without acid and 1 cell with acid which was mononuclear. Cultures were all negative. The patient was treated with supportive care including control of her high blood pressure. However, she became more unresponsive. On August 20, when examined she was making occasional movements only to deep pain. Pupils were 1 to 1.5 mms, hardly reactive. She had marked right gaze preference. Plantar reflexes remained upgoing on the right and equivocal on the left. Later on August 20th the patient had a cardiac arrest and she could not be resuscitated. ---- The findings at autopsy included recent thrombosis of the left vertebral artery and recent/subacute infarcts of left cerebellar hemisphere, striate pons, and pontine tegmentum; and chronic infarcts involving left and right fusiform, lingual gyri and basis pontis and brainstem Lewy bodies.
