1. Clinicopathologic Conference
Presenter: Alexis Steinberg
Pathologist: Dr. Hamilton

2. 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

3. Initial CTH Scan

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

5. MRI – GRE

6. 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

7. CT Three Months Later

8. Diffuse Brain Injury

9. Diffuse TBI Pathology

10. Gross Pathology

11. Microscopic Pathology

12. Microscopic Pathology

13. Sequelae of TBI

14. Gross Pathology

15. Microscopic Pathology

16. Jason Chiang, MD, PhD Neuropathology Fellow, PGY-5 May 20, 2016
PHS
Jason Chiang, MD, PhD
Neuropathology Fellow, PGY-5
May 20, 2016

17. NF

19. GFAP

20. NF