A 93-year-old Woman Presenting Consciousness Disturbance, Left hemiplegia, and Respiratory Distress Hideto Miwa 1 , Natsune Imamura 1 , Yoshihiko Mizutani 1 , Hidetoshi Shiotsu 2 , Noriyuki Kuwabara 2 , Masanori Nagaoka 1 , Takeshi Sato 1,3 , Yoshikuni Mizuno 1 1Departments of Neurology, Juntendo University School of Medicine 2Departments of Pathology, Juntendo University School of Medicine Keyword: cerebral embolism , cerebral infarction , cerebral herniation , atrial fibrillation pp.281-287
Published Date 1993/3/1
DOI https://doi.org/10.11477/mf.1406900462
  • Abstract
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We present a 93-year old female who abruptly developed left hemiplegia on the way to the wash room. She was admitted to another hospital where her consciousness deteriorated and artificial respira-tion was necessary. She was transferred to our hospital 20 days after the onset of her stroke.

On admission, her BP was 60/40 mmHg, and wheezing rale was heard in both lung fields. No heart murmur was present. She was in comatose state, but a small amount of spontaneous move-ments were present in her eyelids and the jaw. Neurologic examination revealed no papilledema, small non-reactive pupils with the right side being slightly larger than the left, absence of ocular movements, and loss of oculocephalic response and corneal reflex. An intratracheal tube was in situ, and the observation of the pharynx was impossible. No stiff neck was present. No spontaneous move-ment was observed in her limbs which were flaccid and all the deep reflexes were lost except for jaw jerk which was weakly positive.

Cranial CT scans revealed low density areas in the right anterior and middle cerebral artery terri-tories with patchy areas of high density being con-sistent with a hemorrhagic infarction. In addition, a small high density mass lesion was noted in the left frontal lobe adjacent to the falx, which was thought to be a small meningioma. Her clinical course was complicated by pneumonia, hypotension and cardiac failure. She expired 2 months after the onset of her stroke.

Postmortem examination revealed an extensive hemorrhagic infarction involving the territory of the right internal carotid artery. Atheroscleroticchanges were not prominent in none of the major vessels intracranially and extracranially, and none of them were stenotic or occluded. Some of the small arteries in the infarcted area were occluded by thrombi. Nodular verrucae were attached to the mitral valve, and in all likelihood, the mitral valveappeared to be the source of her cerebral embolism. Her clinical course was discussed in terms of the central type of transtentorial herniation, however, no Duret hemorrhage was observed in the brain stem.

Copyright © 1993, Igaku-Shoin Ltd. All rights reserved.


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