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Washington University Experience | VASCULAR | Congophilic Angiopathy (CAA) | 3A0 Case 3 History
Case 3 History ---- The patient was an 85-year-old man with a past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and recent seizure diagnosis (2 years prior to death). The patient was in his usual state of health when his wife noticed slurred speech, confusion, right facial droop and right-sided weakness during dinner. At an outside hospital, he was noted to be hypertensive (220/110) and started on nicardipine and given tPA. A subsequent follow-up CT head scan showed an intraparenchymal hemorrhage in the cerebellum; the patient was then emergently transferred to BJH for craniotomy and drain placement, received aminocaproic acid for tPA reversal and intubated. Upon arrival to BJH he had hemorrhage in both cerebellar hemispheres, cerebellar vermis, medial and lateral right temporal lobe, and both occipital lobes. There was also midline hemorrhage causing mass effect on the fourth ventricle. While there was strong suspicion for infection, tracheostomy, blood and CSF cultures were all negative; nonetheless, the patient was started on empiric antibiotics for suspected pneumonia. Through the hospital course, the deceased had increased respiratory secretions and increased FiO2 requirements and bibasilar nodular opacities, so the antibiotic regimen was broadened. Bronchoscopy showed right lower lobe and peripheral upper lobe necrosis suspicious for fungal infection or ischemic injury. Given the persistent desaturations and increased ventilatory support requirements, his family decided to change patient resuscitation status to DNR. ---- At autopsy the unfixed brain weighed 1220g. The patient had Alzheimer disease neuropathologic change, “high probability” by NIA-AA method, cerebral amyloid angiopathy as well as hyaline arteriolosclerosis (Hx of chronic hypertension) and several large hemorrhages/hemorrhagic infarcts in right and left temporal lobes, both cerebellar hemispheres and in his right occipital lobe. In a complex case such as this, there may have several causes for hemorrhagic infarction including CAA, tPA injection with a contribution by arteriolosclerosis.
