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Washington University Experience | VASCULAR | Small Vessel Disease | 8A0 Case 8 History
Case 8 History ---- The patient was a 75-year-old man with a history of prior stroke (resulting in mild right hemiparesis) on coumadin, CABG, and diabetes, who was admitted to an outside hospital on 4/28 after having experienced a loss of consciousness resulting in a fall. His blood sugar at the time of EMS arrival was 27, which was felt to be the etiology of his loss of consciousness. He suffered a right femoral head fracture and was transferred to BJH for surgical fixation, which he underwent on 5/2. After extubation from the procedure, he developed respiratory distress followed by arrest with PEA. He was reintubated, received chest compressions for 2 minutes and epinephrine, with return of pulse and blood pressure. After the arrest, he had elevated troponin I levels and changes on EKG. A head CT on 5/12 showed lacunar infarcts in the left lentiform nucleus and right thalamus, which had been also been present on a CT a year previous. On 5/15, his family elected to withdraw support, and he expired later that day. ---- At autopsy his unfixed brain weighed 1350g. Old lacunar infarcts involved left frontal, entorhinal and occipital cortices, left hippocampus, and right thalamus. The medulla showed a remote infarct involving nearly the entire left pyramid with cavitation. Downstream sections of medulla and spinal cord show tract degeneration resulting from the pyramidal lesion. The left inferior olivary nucleus shows "olivary hypertrophy" consisting of enlargement and vacuolation of neurons of the ION and marked astrocytosis, thought to reflect superimposed ischemia from interruption of descending fibers in the rostral brainstem.
