Table of Contents
Washington University Experience | VASCULAR | Infarct - Venous | 3A0 Case 3 History
Case 3 History (this case is also shown in the Infarct – Spinal Cord section) ---- The patient was a 61 year old man with a past medical history of inflammatory bowel disease, either ulcerative colitis or Crohn’s disease, perforated diverticulitis s/p partial colectomy, coronary artery disease, dyslipidemia, hypertension, and a six-week history of C. difficile colitis being treated with metronidazole. He was admitted on 6/30 with a one-week history of headache, progressive confusion and aphasia. He was febrile but alert, oriented, and ambulatory with a non-focal neurologic exam. The next morning he was somnolent, unarousable, and only responsive to painful stimuli. A head CT and brain MRI revealed massive cerebral hemorrhages in the right and left middle cerebral artery distribution with edema and minimal midline shift. In the ICU he was empirically started on acyclovir for possible herpes simplex encephalitis. Over the next two days he developed left-sided motor deficits which progressed to an absence of spontaneous or reactive movement, seizure activity on EEG, and fixed and dilated pupils. On 7/3 he was extubated, made comfort care only, and shortly thereafter developed respiratory failure and died. ---- At autopsy, brain weight was 1520 grams with large and small hemorrhagic lesions, several involving large areas of the right and left MCA territories, likely resulting from multiple arterial thromboemboli. Although the superior sagittal sinus was free of thrombi, there were numerous thrombi within many cortical leptomeningeal vessels whose walls were intact and not angiitic. The presence of multiple thromboemboli within leptomeningeal arteries and veins, may reflect a hypercoagulable state.
