1. Patient: CO Clinicopathologic Conference (CPC) Friday, October 2 nd, 2015 Neurology Resident: C. Chauncey Spears Pathologist: Drs. Wiley and Murdoch

2. 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)

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

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

5. Mechanism?

6. Treatment?

7. Hospital Course IV tpa @ 1023am  NIH 14 Mechanical Thrombectomy @ 1130am  NIH 10 to 12

8. Hospital Course 9/5 @ 5pm  NIH 15-18, less awake + weaker on L 9/5 @ 6pm MRI Brain

9. Hospital Course 9/6 @ 10am continued poor LOC

10. Uh Oh?!?

11. UPMC Hemicrani Protocol Lancet Neurology, 2007; 6: 215-22

12. UPMC Hemicrani Protocol Eligibility 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

13. Hospital Course 9/6 @ 1pm  Hemicraniectomy

14. 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-up EKG 1 st deg AV block, Trp neg TTE w WF 70%, mild L>R shunt, Mod Pulm HTN TEE with B/L Atrial enlargement, No cardiac source of emboli LDL 65 A1c 6.2 UDS/ETOH neg Hypercoag screening with weak, non dx LAC; Neg otherwise DISCHARGED TO REHAB 9/15!!!

15. Hospital Course …. 9/20 @ 945am while supine CONDITION C dizziness, syncope x 30sec  CP, Diaphoresis, Sinus tachy, TWI in V2 Transferred to Inpt but first to CT Scanner…

16. Hospital Course Condition A in CT GTC 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

17. 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.

18. Predicted Pathology?

19. Predicted Pathology