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Washington University Experience | VASCULAR | Small Vessel Disease | 19A0 Case 19 History
Case 19 History ---- The decedent was a 57 year old man with a history of a right posterior CVA (with residual L hemiparesis) in 1990, a seizure disorder, coronary artery disease, hypertension, diabetes, renal insufficiency, alcohol abuse, and was s/p ventriculoperitoneal (VP) shunt placement (for hydrocephalus) in 1992. He was found at home having a generalized convulsive seizure by his wife. When EMS brought him to the Barnes Hospital ER, he was still in status epilepticus and was treated with IV Ativan and Dilantin. The initial neurological exam in the ER revealed no response to voice. Little spontaneous movement was seen in extremities. He was able to withdraw all extremities to noxious stimuli and had increased reflexes and tone in the left upper extremity. Head CT showed no intracerebral hemorrhage, but significant ventriculomegaly with atrophy, right occipital encephalomalacia and the VP shunt was in place. The patient remained comatose in the NICU, and continued to have focal motor seizures in his left upper extremity. The patient was treated with Phenobarbital, Dilantin, and Tegretol. The initial EEG showed generalized low voltage and right paroxysmal lateralized epileptic discharges (PLEDs). The initial LP was only remarkable for high protein (about 400) with two WBC's. The focal motor seizures stopped and the patient's mental status improved slowly. The repeat EEG on 12/22 did not show PLEDs. The patient developed choreoathetoid movement involving his head and left upper extremity, which disappeared with sleep. The patient remained febrile throughout the hospital stay; however, the only positive culture was urine for E. coli. Even after triple antibiotic treatment, he continued to have fever and leukocytosis. On 12/30, the patient developed abdominal distention and increased NG tube suction output, which was felt to be due to either ileus or small bowel obstruction. The surgery team placed a Dennis tube; however, the patient's obstructive symptoms did not resolve. A Hypaque enema suggested that the patient might have distal ileal obstruction. Another finding was a left supraclavicular mass which suggested a neoplastic process. It was biopsied and turned out to be metastatic calcification. Since the obstructive symptoms persisted with conservative therapies, the patient was brought to the OR on 1/17 for exploratory laparotomy and possible adhesiolysis. In the operating room, the patient developed ventricular tachycardia, which initially responded to lidocaine, but eventually, progressed to asystole. Despite all the efforts including CPR, electrical defibrillation, vasopressors, calcium, etc., the patient expired on 11/17. ---- At autopsy the unfixed brain weighed 1,070g. There were remote cystic infarcts in the right temporal, occipital and parietal lobes. Smaller remote cystic infarcts were present in the basal ganglia, thalamus, and midbrain. Atherosclerotic and arteriolosclerotic vascular disease was severe and multifocal. Diffuse gliosis and fiber loss were identified in the deep white matter.
