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Washington University Experience | VASCULAR | Congophilic Angiopathy (CAA) | 5A0 Case 5 History
Case 5 History ---- The decedent was a 63-year-old man with a past medical history significant for transient ischemic attacks, hyperlipidemia, an incidental right internal carotid artery supraclinoid aneurysm, anxiety/depression, cervical spine fusion, arthritis, and gastroesophageal reflux disease. He was admitted to the cardiac care unit at BJH, transferred from an OSH suffering from chest pain and ST depression on EKG which later resolved without change in serum troponin. He was given anticoagulants prior to transfer, and on arrival at BJH, was started on a heparin drip. Later that night, he started vomiting and was found to have left-sided neglect and hemiparesis. Emergency head CT showed a large right parieto-temporal-occipital intraparenchymal acute hemorrhage, with right to left midline shift, concerning for right sided uncal herniation. A right decompressive craniectomy, duraplasty, and evacuation of intracerebral hemorrhage was emergently performed. His post-operative course was notable for a urinary tract infection, treated with ceftriaxone, with negative blood cultures. An echocardiogram showed normal heart function, and he was started on aspirin. He was unable to be weaned from the ventilator, so a tracheostomy and gastrostomy tube was placed on March 2016. He was discharged to a rehabilitation facility for continued inpatient rehabilitation. The patient started desaturating into the 70s, and blood was noted at both the tracheostomy site and the G-tube. After EMS arrival, the patient went into cardiac arrest. Upon arrival in the emergency department resuscitation was continued but no cardiac movement was seen on ultrasound and the patient passed. ---- At autopsy the weight of the unfixed brain was 1560g. A large, recent right frontal lobe hemorrhage and a subacute right temporal/occipital lobe hemorrhage (S/P surgical drainage) was found with subarachnoid extension. This is a textbook example of lobar hemorrhages arising in a patient with congophilic amyloid angiopathy and intermediate level of Alzheimer Disease Related Change.
