Clinicopathologic Conference Presenter: Alexis Steinberg Pathologist: Dr. Hamilton

History Mr. D is a 41yo M and in 2013, he was in a high speed MVC that resulted in severe TBI. He was intoxicated. He was being chased by police and hit a telephone pole and ejected from vehicle. He was intubated on field. GSC on arrival was 3. Injuries included DAI – multifocal areas of IPH with IVE (SDH and tSAH), ruptured diaphragm, grade 3 liver lac, pneumothorax, T5-T8 spine process fracture, right medial maleolus fracture, facial lac, type 1 odontoid fracture Initial CTH on 02/15, showed multifocal areas of IPH with IVE, SAH, and SDH c/f DAI. Mild loss of gray-white differentiation with mild sulcal and cisternal effacement showing brain edema EVD placed for severe TBI protocol

Initial CTH Scan

MRI – T2 FLAIR Scatterd subcortical suscipitalibilty artifact IPH, SAH, SDH T2 hyperintensity in pons and left brachium pons, shearing injury

MRI – GRE

History Continued He developed hydrocephalus Hospital course c/b DVT on LLE, bacteremia from line infection, DI requiring DDVAP He got a tracheostomy and PEG Per neurosurgery notes, flexed throughout to pain, eyes closed, pupils 6mm fixed, corneals intact (poor neuroexam) SSEP confirmed poor prognosis. SSEP abnormal since absence of cortical response (no N20 waveforms) with subcortical cervical and peripherals preserved, lesion above dorsal column nuclei at cortical level b/l. BEARs were normal. Three months later, his hydrocephalus worsened and he had a VP shunt placed

CT Three Months Later

Diffuse Brain Injury

Diffuse TBI Pathology

Gross Pathology

Microscopic Pathology

Microscopic Pathology

Sequelae of TBI

Gross Pathology

Microscopic Pathology

Jason Chiang, MD, PhD Neuropathology Fellow, PGY-5 May 20, 2016 PHS16-16447 Jason Chiang, MD, PhD Neuropathology Fellow, PGY-5 May 20, 2016

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GFAP

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