Dados do Trabalho

Título

Consecutive hemorrhagic strokes possibly caused by Cerebral Amyloid Angiopathy related to Duraplasty

RESUMO

Case report: A 44-year-old male patient was admitted to our hospital in March 2022 complaining of headache and left homonymous hemianopsia. In the past two years, he had two intraparenchymal hemorrhages, both in the right parietooccipital lobe. Computed tomography showed right parietooccipital intraparenchymal hematoma, left parietooccipital encephalomalacia and signs of a previous left occipital craniectomy. Magnetic resonance imaging confirmed the above findings, also showing several corticosubcortical punctate foci of low signal on SWI sequence predominating on bilateral occipital lobes indicating microbleeds. Angioresonance did not show any abnormalities. These findings support the possible diagnosis of cerebral amyloid angiopathy (CAA) related hemorrhage according to the modified Boston criteria, excluding the age criteria.
The patient had a past medical history of head trauma at the age of 7 years, caused by a reaping hook, for which he underwent a neurosurgical procedure including craniectomy and duraplasty. He had no relevant familiar history of cerebrovascular disease or dementia.
Discussion: CAA is commonly found in older people and in patients with Alzheimer's disease accompanying cerebrovascular disorders and dementia. Cerebral blood vessels affected by CAA are associated with functional and pathological changes, leading to hemorrhagic disorders, such as lobar intracerebral hemorrhage and cortical micro-hemorrhage. It is hypothesized that amyloid-β (Aβ), a pathological hallmark of this condition, is transmissible by a similar mechanism to acquired prion diseases. Furthermore, besides genetic inheritance, it has been described the occurrence of early onset Aβ-CAA associated cerebral hemorrhage, several decades after neurosurgical procedures performed in children involving cadaveric dura mater grafts or neurovascular embolization using material derived from cadaveric dura mater. Due to the early age, temporal association, no family history of stroke, we hypothesize that the duraplasty may be associated with the occurrence of amyloid angiopathy in this patient.
Final considerations: This case illustrates a possible cause of early onset CAA and emphasizes that Aβ-CAA should be considered in the differential diagnosis even for young patients with intracerebral hemorrhage and history of neurosurgery. Furthermore, the exact physiopathology of this condition needs more elucidation due to the possibility of iatrogenic human transmission.

Palavras Chave

Amyloid Angiopathy, Duroplasty, Hemorrhagic stroke, Young hemorrhagic stroke, Early onset