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Washington University Experience | VASCULAR | Infarct - Subacute | 22A0 (Case 22) History
Case 22 History ---- The decedent was a 79-year-old woman with a medical history of hypertension, type 2 diabetes mellitus and chronic kidney disease. Six months prior to her death she suffered a left middle cerebral artery (MCA) infarct with residual right-sided weakness. Susceptibility signal seen in the left MCA was consistent with a thrombus seen on prior CT angiography of February 3, 2026. At that time MRI showed bilateral chronic supra and infratentorial encephalomalacia/infarcts and moderate to severe chronic white matter microvascular disease. Following the stroke, she was bedbound and nonverbal at baseline, although she could communicate to some extent and occasionally feed herself with her left hand. She was hospitalized in April 2026 for malnutrition. She presented again in May 2026, with several days of progressively worsening abnormal jerking movements that interfered with oral intake. At that time neurologic evaluation included CT and MRI of the brain, which demonstrated no acute intracranial abnormalities. EEG demonstrated central epileptiform discharges, diffuse slowing, and intermittent discontinuity, consistent with increased seizure risk and diffuse cerebral dysfunction in the setting of underlying structural brain disease and possible metabolic contributions. Her abnormal movements improved following benzodiazepine treatment, and she was maintained on Keppra 500 mg every 12 hours. During the prolonged hospitalization, the patient had minimal to absent oral intake with severe protein-calorie malnutrition, cachexia/wasting syndrome, dysphagia, failure to thrive, and markedly reduced mobility. She remained bedbound with hemiplegia and limited range of motion. Her family declined feeding tube placement in accordance with her reported prior wishes. Following goals-of-care discussions with her sister, acting as POA, the patient was transitioned to comfort-focused care. Intravenous fluids were discontinued, medications were adjusted for comfort, and oral swabs and food as tolerated were offered. The patient subsequently expired in mid-July 2026.
