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Washington University Experience | VASCULAR | Small Vessel Disease | 9A0 Case 9 History
Case 9 History ---- The patient was a 76 year old man who had a history of smoking and alcohol abuse, received a clinical diagnosis of Alzheimer's disease, and experienced a stroke in 2009 (4 years prior), which resulted in residual right-hand weakness, bowel and bladder incontinence, and reduced ability to ambulate. On 4/1 he fell out of bed and exhibited agonal breathing. The patient's wife performed CPR and activated Life Alert. The patient arrived to the ED with pulseless electrical activity. At 12:56 the patient's pulse returned and at 20:57 the patient was having ventricular tachycardia. The patient appeared to be hypovolemic. A cooling protocol was initiated but was subsequently discontinued. The patient remained on maximum support with vasopressin, epinephrine, dopamine, and Levophed. The patient remained on mechanical ventilation. Head CT on 4/1 showed ex-vacuo dilation of the ventricular system, microangiopathic changes in the white matter, and old lacunar infarcts in the basal ganglia, right thalamus and right cerebellum, but no acute intracranial or extra-axial process. The patient's condition failed to improve. On 4/2 the patient was found pulseless, without heart tones or blood pressure. ---- At autopsy the weight of the unfixed brain was 1150g. Acute infarcts involved bilateral MCA and PCA territories with remote small infarcts in occipital cortex, basal ganglia, thalamus, brainstem, and cerebellum. Underlying vasculature was severely involved by atherosclerosis and arteriolosclerosis. He received a diagnosis of argyrophilic grain disease, stage I and Alzheimer's disease neuropathological change: A1, B1, C1 (mild). The history available did not describe longstanding hypertension; however, indirect evidence included cardiomegaly (500g), left ventricular wall thickness of 1.7cm and accompanying nephrosclerosis provides evidence for significant chronic hypertension.
