Patient: COClinicopathologic Conference (CPC)

Friday, October 2nd, 2015

Neurology Resident: C. Chauncey SpearsPathologist: Drs. Wiley and Murdoch

History – ED Presentation @ 935am, 9/5/15

CO is a 39yo Kenyan born man with no known medical problems or stroke risk factors who presented on 9/5/15 after being involved in a low speed MVA at work with notice of R gaze deviation + L-sided hemiplegia thereafter; LSW 830am / mRS 0.

VS ok. (SBP < 185)Acute stroke labs ok. (Hb, Plts, BUN:Cr, Glu, INR, trp)NIH 14 (1 R gaze, 2 L FP, 3 LUE, 3 LLE, 1 L sens, 2 Dysarthria, 2 L Ext/Neglect)

CTH / CTA @ 945am, 9/5/15[ASPECT ?]

CTH / CTA @ 945am, 9/5/15

Mechanism?

Treatment?

Hospital Course

IV tpa @ 1023am NIH 14Mechanical Thrombectomy @ 1130am NIH 10 to 12

Hospital Course

9/5 @ 5pm NIH 15-18, less awake + weaker on L9/5 @ 6pm MRI Brain

Hospital Course

9/6 @ 10am continued poor LOC

Uh Oh?!?

UPMC Hemicrani Protocol

Lancet Neurology, 2007; 6: 215-22

UPMC Hemicrani ProtocolEligibility criteria• For prophylactic decompression (ie, decompression prior to clinical worsening)

– Age 18 – 70 years without evidence of significant pre-existing co-morbidities– Clinical deficits suggestive of infarction in the territory of the MCA with a score on the National Institutes of Health stroke

scale (NIHSS) >12 for dominant hemisphere, > 10 for non-dominant.– Stroke volume >180 ml

• For early therapeutic decompression (ie, within 48 hours of admission)– Age 18–60 years, > 60 years may be considered based on the absence of co-morbidities and level of function– Clinical deficits suggestive of infarction in the territory of the MCA with a score on the National Institutes of Health stroke

scale (NIHSS) >12 for dominant hemisphere, > 10 for non-dominant.– Decrease in the level of consciousness to a score of 1 (ie, not alert, but arousable with minimal stimulation) or greater on

item 1a of the NIHSS.– Signs on CT or MRI (preferred) of an infarct involving a stroke volume of > 150ml.

Exclusion criteria• Absolute contraindications

– Pre-stroke score on the mRS ≥ 3• Two fixed dilated pupils• GCS < 4 without improvement in the first 24 hours• Known irreversible coagulopathy or systemic bleeding disorder• Relative contraindications

– Complete ICA distribution ischemia on affected side• Contralateral ischemia or other brain lesion that could affect outcome• Medical co-morbidities that impact on life expectancy• Other serious illness that could affect outcome

Hospital Course

9/6 @ 1pm Hemicraniectomy

Hospital Course

9/6 @ 4pm (post op) NIH 29 (intubated)9/7 NIH 15-20 after self extubation

9/7 to 9/15 NIH 12

Stroke Work-upEKG 1st deg AV block, Trp neg

TTE w WF 70%, mild L>R shunt, Mod Pulm HTNTEE with B/L Atrial enlargement, No cardiac source of emboli

LDL 65A1c 6.2

UDS/ETOH negHypercoag screening with weak, non dx LAC; Neg otherwise

DISCHARGED TO REHAB 9/15!!!

Hospital Course

…. 9/20 @ 945am while supineCONDITION C

dizziness, syncope x 30sec CP, Diaphoresis, Sinus tachy, TWI in V2

Transferred to Inpt but first to CT Scanner…

Hospital Course

Condition A in CTGTC Seizure (2mg ativan)

Pulseless Arrest, EKG STEMI Anterior Leads- Chest compressions x 50min

- Epi (> 20)- Vasopressin 40u

- Calcium Gluconate x4- Bicarb x5

- Bedside Echo = no cardiac wall motion

Time of Death = 9/20 @ 1130am

Autopsy

• Large, acute pulmonary emboli occluding R and L main pulmonary arteries.

• No A-V shunt

• Neuropath ……

*Of note, patient was receiving daily therapy with ASA 81mg + sc hep at 5000iu q8h throughout rehab stay.

Predicted Pathology?

Predicted Pathology