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Washington University Experience | VASCULAR | Subcortical Arteriosclerotic Encephalopathy | 6A0 Case 6 History
Case 6 History ---- The patient was a 62 year-old woman with a history of old left subcortical cerebrovascular accidents, congestive heart failure, coronary artery disease, and end stage renal disease on hemodialysis and diabetes. She was taken to the BJH ER on 8/19 for mental status change characterized by confusion and agitation, and then had a short episode of unresponsiveness, followed by vomiting, bradycardia (heart rate ~40) and dyspnea. There was no definitive diagnosis of dementia separable from her metabolic status. In the ER, she was described as confused, agitated, diaphoretic and cyanotic. No focal weakness was reported. The laboratory data showed WBC 15.3, Hemoglobin 11, Hct 35%, creatinine: 9.1, BUN: 49, glucose: 367, pH: 7.3, PCO2 18, PO2 302. Soon, she became unresponsive, and developed agonal breathing. She received CPR for 45 min and was intubated and treated with pressors but expired. ---- At autopsy the weight of the unfixed brain is 1100 gm. Coronal sections of the cerebral hemispheres showed both left and right lateral ventricles are dilated with blunting of the angles. An old infarct that involves left caudate, globus pallidus and putamen. The soft area of the right parietal lobe is roughly wedge-shaped, consistent with an infarct. The right thalamus and mamillary body are smaller in size compared to their left counterparts. Multiple old infarcts with cystic degeneration, ranging in size from 0.3 cm to 0.6 cm, are noted in the white matter of bilateral cerebral hemispheres (centrum semiovale), including the supercallosal regions and area close to the right internal capsule. The corpus callosum is markedly atrophic. Sections of frontal, parietal, temporal and occipital neocortexes show relatively well maintained complement of neurons. No amyloid plaques or neurofibrillary tangles are were identified. Multiple old infarcts (with or without central cystic changes) composed of foamy macrophages and reactive astrocytes are noted in left and right basal ganglia and multiple regions of white matter. The neuropathologic final diagnosis was arteriolosclerosis with multiple lacunar infarcts and microinfarcts, including basal ganglia and centrum semiovale, wedge-shaped old infarct in the right occipital lobe. I include this case without a definitive diagnosis of dementia to illustrate the difficulty of correlating clinical symptoms with pathology.
