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Washington University Experience | VASCULAR | Infarct - Venous | 8A0 Case 8 History
Case 8 History ---- The patient was a 33 y/o obese, hypertensive, G2P1 woman admitted at term to an OSH for induction of labor. Pregnancy had been uncomplicated except for oligohydramnios and proteinuria. After five days of unsuccessful pharmacologic induction, a normal infant was delivered by Cesarean section. There were no intraoperative complications. However, on POD #3, the patient was brought back to the OR for wound closure after dehiscence. On POD #5, the patient developed a vertex headache and low grade fevers that had remitted by POD #7. The patient also developed worsening proteinuria and renal insufficiency. On POD #10, the patient was found stuporous. A blood gas revealed PO2=44, with mild respiratory acidosis. CXR showed new cardiomegaly and pulmonary interstitial infiltrates. Neurologic examination was notable for stupor and mild diffuse hypotonia, without lateralizing neurological signs. Over the next 24 hours she became more readily arousable, but remained confused and agitated. CT scan was unremarkable without contrast. LP was notable for an opening pressure between 450 and 500 mm H20, though interpretation was limited by the patient's agitated status. CSF examination showed no leukocytes, a few RBCs without xanthochromia, no organisms on Gram stain, and normal protein and glucose. Over the next five days, her mental status improved, but she remained intermittently agitated and lethargic. The patient responded well to diuresis with resolution of hypoxia and pulmonary infiltrates. By POD #15, the patient still showed altered mentation, but was ambulatory within her room, was eating well, and spoke with her mother on the telephone. On POD #17, the patient was found in her room unresponsive with a fixed and dilated left pupil and right hemidecorticate posturing. A repeat CT scan with and without contrast was performed showing extensive left hemisphere infarction crossing arterial boundaries with some hemorrhagic component and a "delta sign" consistent with sagittal sinus thrombosis. Despite hyperventilation and mannitol, the patient's herniation syndrome progressed. She was transferred to BJH for consideration of an emergency procedure, but was pronounced brain dead shortly after arrival. ---- At autopsy the unfixed brain weight was 1430g. There were extensive occlusive thrombi involving the superior sagittal and lateral venous sinuses and cortical veins. These were accompanied by venous infarcts in the left frontal and parietal lobes.
