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Washington University Experience | VASCULAR | Infarct - Venous | 9A0 Case 9 History
Case 9 History ---- The patient was a 42 year woman with an unremarkable past medical history who expired following a 4-5 day history of progressive neurologic illness. Her illness began after several days of nausea, vomiting and facial pain, treated with antibiotics for a proposed sinus infection. She later developed right-sided weakness and was seen at an OSH. A CT scan showed a low attenuation lesion in the right parietal lobe, lacking hemorrhage, with mild mass effect at that time. After BJH transfer she continued to have right-sided weakness and word finding issues. There was no history of a fall or trauma, hypertension, cardiovascular disease, or diabetes. An angiogram showed a superior sagittal sinus thrombosis and possible right transverse sinus occlusion. Clot degradation was attempted without success. The patient was placed on low-dose Heparin. Over the next 24 hours her neurologic status declined rapidly. She became comatose with mid-sized, fixed pupils and absent brainstem reflexes and she didn’t respond to painful stimuli in all four extremities. An intracranial pressure monitor showed marked increase at 124 with mean arterial pressure of 82/130. She had received Mannitol at the outside hospital. A repeat head CT showed bilateral lesions, right greater than left, with extensive brain edema and obliteration of the ventricles, sulci, and cisterns. There were also new parenchymal hemorrhagic lesions identified. Both the clinical, angiographic, and imaging findings were consistent with the diagnosis of superior sinus thrombosis. The patient was declared clinically brain dead and her organs donated. ---- At autopsy her unfixed brain weighed 1360 g. There was thrombosis of the superior sagittal and transverse venous sinuses with hemorrhage and necrosis involving the right temporal/parietal region which resulted in right uncal and cerebellar tonsillar herniation and Durét hemorrhages in midbrain and pons. The leptomeningeal veins originating in the superior sinus were often thrombosed and extended over the superior aspects of the cerebral cortex. There was diffuse cerebral edema which was most extensive in the right hemisphere.
