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Patient J.M. Clinicopathologic Conference (CPC) 4/1/16

Patient J.M. Clinicopathologic Conference (CPC) 4/1/16. Neurology Resident: Natalia Gonzalez Pathologist: Clayton Wiley. History. 67 year old right handed woman with a hx of uncontrolled T2DM, HTN, and HLD OSH 2/29 with 2 weeks dizziness, falling towards right, N/V

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Patient J.M. Clinicopathologic Conference (CPC) 4/1/16

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  1. Patient J.M.Clinicopathologic Conference (CPC) 4/1/16 Neurology Resident: Natalia Gonzalez Pathologist: Clayton Wiley

  2. History 67 year old right handed woman with a hx of uncontrolled T2DM, HTN, and HLD • OSH 2/29 with 2 weeks dizziness, falling towards right, N/V • Mild heaviness and numbness RUE

  3. Physical Examination MS: Alert, oriented. Language intact, able to name, repeat. Attention intact. CN: II-XII intact Motor: No drift of any extremity. Decreased RAM in RUE. Sensation: Decreased to light touch RUE. No extinction. Coordination: Intact

  4. Initial imaging MRI

  5. DSA • Right ICA multifocal stenosis and right V2 occlusion

  6. Workup - TTE: EF 20% - LDL 132 - Hba1c 9.4 Presumed embolic etiology secondary to reduced EF and discharged to rehab on warfarin.

  7. One week later… New left facial droop and left sided weakness. Glucose 50 and respiratory failure. Weakness improved slightly after glucose repletion. CTH with petechial staining of R parieto-occipital lesion. CTA same. MRI with tiny new acute infarcts in the right putamen. Warfarin was held.

  8. Course Developed worsening respiratory failure, intubated. Thought likely secondary to combination of heart failure and pneumonia. Septic shock requiring pressors. Exam fluctuated. Repeat MR…

  9. Pt passed after a PEA arrest.

  10. Pathology of diffuse hypoxia-ischemia • In acute stage, brain appears congested and dusky. Diffuse cerebral swelling with gyral widening and sulcal narrowing (“cytotoxic edema”). • Borderzones (“end-artery”regions) • and those of vertebraobasilar regions • are preferentially affected.

  11. Brain cells differ in susceptibility to hypoxia • Neurons>oligodendrocytes>astrocytes>endothelail cells • Neuron subsets: • - Pyramidal cells in CA1 area • of hippocamus (“Sommer’s sector”) • - Purkinje cells of cerebellum • With severe insults, necrosis of layers II, V, VI of cortex or total loss of all cortical layers.

  12. Gross photos

  13. Gross photos

  14. Gross photos

  15. Gross photos

  16. Gross photos

  17. References Neuropathology. Richard Prayson. 2012.

  18. Virtual Microscopy Cortex Slide A H&E GFAP CD68 Neurofilament NeuN

  19. Virtual Microscopy Hippocampus B H&E GFAP CD68 Neurofilament

  20. Virtual Microscopy Basal Ganglia Slide F H&E GFAP CD68 Neurofilament NeuN

  21. Virtual Microscopy Basal Ganglia Slide C H&E GFAP CD68 Neurofilament

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