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Washington University Experience | VASCULAR | Congophilic Angiopathy (CAA) | 27A0 Case 27 History
Case 27 History ---- The patient was an 86 year old woman with a history of hypertension and lower GI bleed who was in her usual state of health until the evening prior to admission. At that time her husband noted a sudden onset of unintelligible speech which lasted for 30 minutes. Her husband left to telephone for help and returned immediately to find her unconscious on the floor. She was breathing but not responsive to verbal or tactile stimulation. In the BJH ER, she was witnessed to have a generalized tonic-clonic seizure lasting approximately 1 to 2 minutes. Her vital signs were blood pressure 190/120, pulse 80, respirations 20 and a temp of 38.1. On neurologic exam her head was atraumatic. Her deep tendon reflexes were symmetric and her toes were both upgoing. Her neurologic exam appeared to be nonfocal, the CT of the head was initially postponed. The CSF opening pressure was 20 cm of water and 17 cc of pink, cloudy fluid was sent for studies. The CSF glucose was 73, the protein was 69. There were 3193 total cells, 3 of which were nucleated (all monos). The first CT scan of the head showed a well circumscribed left posterior parietal hemorrhage. There was also evidence of a small left frontal subdural hemorrhage. One day after admission, the patient appeared to worsen. She had minimal response to deep pain. She was not moving her left side much and had minimal movement of the right arm. Both toes remained upgoing. She had skewed deviation of her eyes. Repeat head CT on 5/6 revealed a large left subdural hematoma extending from the frontal to the parietal region with significant midline shift. The left parietal intraparenchymal hemorrhage was unchanged. The patient developed anisocoria with the right pupil 2.5 mm, left 3.5 mm and reactive. She was intubated and hyperventilated as well as given mannitol and Decadron. Despite all efforts, she became progressively more unresponsive and lost all brainstem function. Her platelets dropped from 238,000 to 9,000 over her hospital course. Also her bleeding time was elevated to 11.5 minutes; however, her PT and PTT remained normal. Because of her serious medical condition, she was made no code and subsequently expired. ---- At autopsy her brain weight was 1120g. She was diagnosed with an acute intraparenchymal hemorrhage in the occipital lobe due to congophilic angiopathy in the setting of Alzheimer disease. Swelling precipitated cingulate gyrus and uncal herniation with pontine Duret hemorrhages. Subarachnoid and subdural hemorrhage was found involving the left frontal cortex. The scenario was thought to be acute intraparenchymal hemorrhage in the left occipital cortex secondary to congophilic angiopathy resulting in a fall, striking her head and producing the subdural and subarachnoid hemorrhages.
