Contributed by Seamus Looby1, Derval Royston2, Francesca Brett2
1Radiology Department and 2Neuropathology Department, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
CLINICAL HISTORY AND IMAGING
This 78 year old lady with a past medical history of rheumatoid arthritis, bronchiectasis, hypertension, gastro-oesophageal reflux disease and paroxysmal atrial fibrillation was admitted to hospital following a mechanical fall whilst at a dance class. After the fall she had difficulty putting her weight on her left leg and her friend took her to the Emergency Department. On examination her left leg was shortened and externally rotated.
Pelvic X-ray confirmed the presence of a fractured neck of femur (Figure 1a). The following day she underwent left hip hemiarthroplasty under spinal anaesthetic (Figure 1b). Post operatively she was unrousable. CT showed patchy hypo densities in the frontal and parietal white matter in a watershed distribution (Figure 1c). FLAIR confirmed extensive confluent signal abnormalities in the frontal, parietal, temporal and occipital white matter (Figure 1d). DWI showed patchy foci of diffusion restriction (Figure 1e). Following a discussion with the patient's family a decision was made to employ comfort measures and she died 4 days after admission.
GROSS AND MICROSCOPIC PATHOLOGY
Examination of the brain at autopsy showed an oedematous brain with tentorial and tonsillar herniation (Figure 1f). Serial coronal slices through the cerebral hemispheres showed multiple petechial haemorrhages scattered throughout the brain involving principally the white matter but also the deep grey matter (Figure 1g).
Microscopic examination confirmed widespread petechial haemorrhages with perivenular and cortical micro infarcts (Figure 1h). In some areas these areas of infarction are more advanced manifesting as perivascular macrophages and haemosiderin deposition, and micovascular proliferation. Hypoxic red dead neurones were numerous (Figure 1i). Vessels were plugged by embolic material (Figure 1j). What is your diagnosis?