The 108th Monthly Clinicopathological Conference of Odawara Municipal Hospital on June 8 1998SN-839 OOOO, XXXX 61 y. female Date of Autopsy: 1998.3.9 (30 hours post mortem)
-------------------Clinical Diagnosis by the Dept. of Cardiol.:
1. Congestive heart failure 2. Diabetes mellitus 3. Ischemic heart disease, suspected
Patho-anatomical diagnosis by Dr. Hasegawa of the Dept. of Pathol. and Lab. Med.:
1. Complete occlusion of the left common carotid artery by atheromatous plaque with thrombosis and calcification, involving 8 cm long cephalically from the point 1 cm from the aortic orifice. Arteriosclerosis of the right common carotid artery, severe, with ulceration and calcification, but without obstruction.
2. An old cystic anemic infarct of the right parieto-occipital lobe, facing the longitudinal fissure of the cerebrum, measuring 4 x 2 x 1 cm in dimension, in association with lacunae of the bilateral caudate nuclei and the left putamen. Externally fairly symmetric brain without distinct midline shift at sections (1,090 g). Histologically, a cystic cavity surrounded by loose glial tissue with minimal or no hemosiderin deposition or foam macrophage mobilization.
3. Moderate neuronal loss of the right Ammon's horn with degeneration and shrinkage of cell bodies, whereas almost unremarkable neuronal cells of the left Ammon's horn. Retraction of the cell body and pyknosis of the nuclei of the nerve cells of the cerebral cortex, diffuse and moderate. Unremarkable pigmented neuronal cells of the substantia nigra and locus ceruleus.
4. Mild pallor (secondary degeneration) of the right pyramis just above the level of the decussation of the caudal medulla.
5. Arteriosclerosis of the central nervous system;
a. cut ends of the bilateral internal carotid artery, with fibrous intimal thickening with calcium deposits and almost intact internal elastic lamina, with up-to-30% stenosis.
b. right middle cerebral artery, accompanying an unruptured saccular aneurysm (berry aneurysm) without intrasaccular thrombosis, located at the first branch point deep in the Sylvian fissure, measuring 4 x 4 mm in external dimension. The distal portion of the MCA showing hyalinous degeneration of the wall with luminal obstruction by fibrous tissue.
c. left middle cerebral artery, with up-to-20% stenosis.
d. bilateral vertebral and basilar arteries, mild, with up-to-20% stenosis.
B. Related findings to A:
1. Diabetic nephropathy; mildly nodular surface of the kidneys (150; 140 g) with arteriosclerotic scars and rather patent lumen of the renal hilar arteries. Histologically, diffuse increase in mesangial matrix of the glomeruli (diffuse lesions), Kimmelstiel-Wilson nodules (nodular lesions) surrounded by capillaries, and exudative lesions with a hyaline cap. Arteriosclerosis of arcuate and interlobular arteries, marked, with fibrously thickened intima embedding cholesterol crystals.
2. Langerhans' islets of the pancreas apparently remaining intact by HE-stain, with very rare hyalinous degeneration.
3. Atherosclerosis of the whole length of the aorta, severe, with ulceration and calcification, only sparing the cardiac base, accompanying a fusiform aneurysmal dilatation of the lower abdominal aorta, measuring 7 x 6 cm.
4. Concentric hypertrophy of the left ventricle of the heart with mild dilatation (580 g), macroscopically and microscopically without prominent ischemic fibrotic scar. Coronary arteriosclerosis with scattered atheromas, moderate, with up-to-70% stenosis. Histologically, very localized myocardial coagulative necrosis of the papillary muscles of the posterolateral aspect of the left ventricle.
5. Multiple small infarcts of the spleen (150 g), measuring up to 3.0 x 1.5 cm in size. Arteriosclerosis of the pancreaticosplenic artery, marked. Histologically, coagulative necrosis with occluded artery containing cholesterol crystals.
C. Other findings:
1. Congestion of the liver (1,420 g), moderate. Histologically, mild and focal fatty metamorphosis.
2. Anthracosis of the fairly well-aerated lungs (weight; ND), mild, with yellow clear pleural effusion (50; 280 ml), without adhesion.
3. Mixed bone marrow of the upper third of the femur, the lumbar vertebrae and the sternum.
4. Interstitial fibrosis of the thyroid (18 g), with ectopic thyroid tissue in a regional lymph node.
5. Cyst of the pars intermedia of the pituitary gland, measuring 6 x 5 mm in dimension.
6. Unremarkable adrenals (9.8; 6.5 g).
7. Well-nourished female cadaver (155 cm/ 49 kg). Status post CAVH.
Clinical Summary: Her past medical history is positive for hypertension since the age of 20's, attacks of cerebral infarct with left hemiparesis at the age of 52 (rt. ACA area) and with dysarthria at the age of 58 (lt. thalamus). She was emergently admitted to Ozawa Hospital on November 18 1997 because of acute onset of dyspnea, diagnosed with heart failure, then discharged on December 28. She was admitted again to that hospital on January 2 1998 because of relapse of heart failure, and transferred to OMH for intractable heart failure on March 5. Admission examination revealed increase of CTR, pulmonary edema, and anuria (acute renal failure). CAVH started with effective results. Consciousness deteriorated since March 7, in association with hypotension with shock (BP 50/), followed by death on March 8.
Comments: An occlusion of the left common carotid artery due to arteriosclerosis with thrombosis was likely a contributory factor to consciousness disturbance at the terminal stage, but the underlying cause of death was generalized arteriosclerosis with diabetes mellitus and diabetic nephropathy with renal failure. Infarcts of the spleen suggest the occurrence of thromboembolism in the past. Demyelination of the right pyramidal tract was demonstrated, though of mild degree, just above the decussation, whereas the left pyramis was almost unremarkable. Anoxic change of the neuronal cells of Ammon's horn was more prominent in the right side than in the left as well.
Cause of Death: Arteriosclerosis associated with diabetes mellitus with nephropathy, Occlusion of left common carotid artery
Manner of Death: Natural
A. Hasegawa. MD, PhD
Certified Pathologist (#832 by the Japanese Society of Pathology), Odawara/Tokyo.
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