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Washington University Experience | VASCULAR | Infarct - Venous | 10A0 Case 10 History
Case 10 History ---- The patient was a 70 year old man who was admitted for emergency evacuation of bilateral subdural hematomas on 10-5, and died on 10-12. He had a past medical history of atrial fibrillation, hypertension, and hydrocephalus status-post VP shunt four months earlier for presumed NPH. Two days prior to his admission to the hospital he awoke with dizziness, right frontal headache, nausea, vomiting and severe gait instability. His symptoms improved minimally over the next couple of days and received a head CT on admission which revealed his ventricles to be small with the shunt in place; however, it also demonstrated a right frontal acute subdural hematoma, approximately 1.0 cm thick and a left frontal chronic subdural hematoma with minimal mass effect. On admission, his neurologic exam was normal. The patient underwent a right frontal craniotomy and a left burr hole on 10-5 for evacuation of his subdural hematomas, had no intraoperative or post-operative complications, and was transferred to the floor two days later on 10-6. However, the evening of 10-6, he was a little more lethargic and confused, and later on 10-7 the patient was found on the floor by the nurse lying in a pool of blood. He had had epistaxis and was unresponsive. The patient was intubated at that time and transferred to the Neuro ICU for further care. CT in the ICU showed diffuse swelling as manifested by obliteration of his lateral and third ventricles. His exam at that time showed his right pupil to be larger than his left with a left-gaze preference and a hemiparesis on his right. The motor exam on the left was intact. The patient underwent an MRI and an MRA which were suggestive of superior sinus thrombosis that was confirmed by an angiogram performed on 10-7 and an (unsuccessful) attempt was made to lyse the thrombus in the superior sagittal sinus. Over the next few days the patient continued to show marginal improvement with no major change in his neuro exam and slight improvement of his mental status; however, the patient had acute cardiorespiratory failure on 10-12, was coded, and died. ---- Autopsy showed an unfixed 1350g brain weight. Findings included superior sagittal and right transverse sinus thromboses with acute and chronic bilateral subdural hematomas, a resolving infarct in the right cerebellum and numerous resolving microinfarcts involving the left corpus callosum. Within the venous sinuses there is evidence of thrombi of varying histologic ages. In the anterior region of the superior sinus there is old organized thrombus with evidence of recanalization, whereas in the posterior region of the superior sagittal sinus there is fairly recent thrombus with red blood cells still recognizable. The findings in the right transverse sinus indicate older, recanalized thrombus. In addition, the infarct within the right cerebellum is associated with blood vessels which contain organizing thrombus. This cerebellar infarct appears subacute and would correlate temporally with the patient's presentation on 10-4 with severe gait instability. Neuropathologic examination does not demonstrate an underlying source for this patient's multiple CNS thrombi. The presence of a large pulmonary embolus suggests a hypercoagulable state in this patient. No occult neoplasms were identified and the cardiac valves were free of thrombi. At autopsy, hydrocephalus was not apparent, though the ventricular shunt and cerebral edema associated with the venous sinus thrombosis likely had diminished any possible residual hydrocephalus
