Plasma beta-amyloid and white matter lesions in AD, MCI, and cerebral amyloid angiopathy

BACKGROUND

Microvascular brain injury, typically measured by extent of white matter hyperintensity (WMH) on MRI, is an important contributor to cognitive impairment in the elderly. Recent studies suggest a role for circulating beta-amyloid peptide in microvascular dysfunction and white matter disease.

METHODS

The authors performed a cross-sectional study of clinical, biochemical, and genetic factors associated with WMH in 54 subjects with Alzheimer disease (AD) or mild cognitive impairment (AD/MCI) and an independent group of 42 subjects with cerebral amyloid angiopathy (CAA). Extent of WMH was determined by computer-assisted volumetric measurement normalized to intracranial size (nWMH). Biochemical measurements included plasma concentrations of the 40- and 42-amino acid species of beta-amyloid (Abeta40 and Abeta42) detected by specific enzyme-linked immunosorbent assays.

RESULTS

Plasma Abeta40 concentrations were associated with nWMH in both groups (correlation coefficient = 0.48 in AD/MCI, 0.42 in CAA, p < or = 0.005). Plasma Abeta40 remained independently associated with nWMH after adjustment for potential confounders among age, hypertension, diabetes, homocysteine, creatinine, folate, vitamin B12, and APOE genotype. The presence of lacunar infarctions was also associated with increased Abeta40 in both groups. nWMH was greater in CAA (19.8 cm3) than AD (11.1 cm3) or MCI (10.0 cm3; p < 0.05 for both comparisons).

CONCLUSIONS

Plasma beta-amyloid 40 concentration is independently associated with extent of white matter hyperintensity in subjects with Alzheimer disease, mild cognitive impairment, or cerebral amyloid angiopathy. If confirmed in longitudinal studies, these data would suggest circulating beta-amyloid peptide as a novel biomarker or risk factor for microvascular damage in these common diseases of the elderly.

Antiplatelet use after intracerebral hemorrhage

BACKGROUND

Survivors of intracerebral hemorrhage are at risk for recurrent intracerebral hemorrhage and ischemic cardiovascular and cerebrovascular disease.

OBJECTIVE

To determine whether antiplatelet therapy increases the risk of recurrent intracerebral hemorrhage.

METHODS

The authors reviewed data from consecutive survivors of primary intracerebral hemorrhage enrolled in a single-center prospective cohort study. Survivors were followed by telephone interview; recurrent intracerebral hemorrhage and post-index antiplatelet agent use and duration were recorded. Cox proportional hazards models was used with antiplatelet agent exposure as a time-dependent variable to assess the effect of antiplatelet agent use on recurrent intracerebral hemorrhage, stratified by lobar and deep hemispheric location.

RESULTS

Recurrent intracerebral hemorrhage was more common in survivors of lobar hemorrhage compared with survivors of deep hemorrhage (cumulative 2-year rate 22% vs 4%; p = 0.007). Antiplatelet agents were prescribed in 22% of intracerebral hemorrhage survivors (27/127 lobar, 19/80 deep hemispheric), most commonly for prevention of ischemic heart disease. Antiplatelet agent use was not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage (hazard ratio [HR] 0.8, 95% CI 0.3 to 2.3, p = 0.73) or of deep hemorrhage (HR 1.2, 95% CI 0.1 to 14.3, p = 0.88).

CONCLUSION

Antiplatelet agent use is relatively common following intracerebral hemorrhage but did not appear to be associated with a large increased risk of intracerebral hemorrhage recurrence in this observational study.

Current Pharmacotherapy for Alzheimer's Disease

Alzheimer's disease (AD) is an age-related neurodegenerative disease that affects approximately 4.5 million people in the United States. The mainstays of current pharmacotherapy for AD are compounds aimed at increasing the levels of acetylcholine in the brain, thereby facilitating cholinergic neurotransmission through inhibition of the cholinesterases. These drugs, known as acetylcholinesterase inhibitors (AChEIs), were first approved by the U.S. Food and Drug Administration (FDA) in 1995 based on clinical trials showing modest symptomatic benefit on cognitive, behavioral, and global measures. In 2004 the FDA approved memantine, an NMDA antagonist, for treating dementia symptoms in moderate to severe AD cases. In clinical practice, memantine may be co-administered with an AChEI, although neither drug individually or in combination affects the underlying pathophysiology of dementia. Dementia in AD results from progressive synaptic loss and neuronal death. As knowledge of the mechanisms responsible for neurodegeneration in AD increases, it is anticipated that neuroprotective drugs to slow or prevent neuronal dysfunction and death will be developed to complement current symptomatic treatments.

Association of homocysteine with plasma amyloid β protein in aging and neurodegenerative disease

BACKGROUND

Elevated plasma total homocysteine (tHcy) is a risk factor for cardiovascular disease and is reported to be an independent risk factor for Alzheimer disease (AD) and cognitive decline. tHcy may potentiate neurotoxic and vasculopathic processes, including amyloid beta protein (Abeta) metabolism, implicated in neurodegenerative diseases.

OBJECTIVE

To examine the relationship of plasma total tHcy levels with clinical, demographic, biochemical, and genetic factors in aging, mild cognitive impairment (MCI), AD, cerebral amyloid angiopathy (CAA), and Parkinson disease (PD).

METHODS

Plasma tHcy, folate, vitamin B(12), creatinine, and Abeta levels were assessed in individuals evaluated in the Memory, Stroke, and Movement Disorders Units of Massachusetts General Hospital with diagnoses of AD (n = 145), MCI (n = 47), PD (n = 93), CAA (67), hypertensive intracerebral hemorrhage (hICH) (n = 25), and no dementia (n = 88).

RESULTS

The tHcy levels did not differ across AD, MCI, CAA, hICH, and nondemented control subjects but were increased in the PD group (p < 0.01). The elevated levels within the PD group were due to high tHcy in individuals taking levodopa (p < 0.0001). Increasing tHcy was associated with worse cognition in the PD cases, but not the other diagnostic groups. tHcy levels positively correlated with plasma Abeta levels even after adjustments for age and creatinine (p < 0.0001).

CONCLUSIONS

Mean tHcy levels increased with age but did not discriminate diagnostic groups aside from significant elevation in patients with PD taking levodopa. The positive association between tHcy and plasma Abeta levels raises the possibility that these circulating factors could interact to affect AD risk and cognition in PD.

White matter lesions, cognition, and recurrent hemorrhage in lobar intracerebral hemorrhage

BACKGROUND

Accumulating evidence suggests that white matter lesions are associated with vascular cognitive impairment. The authors investigated the relationships between white matter lesions, cognitive impairment, and risk of recurrent hemorrhage in a prospectively identified cohort of patients with lobar intracerebral hemorrhage (ICH).

METHODS

The authors collected clinical and genetic information on 182 consecutive patients age > or = 55 who had CT scan at admission for lobar ICH. White matter disease was graded on CT in all subjects and on MRI in a subset of 82 patients. All scans were interpreted blinded to clinical information. Survivors were followed for recurrent ICH by telephone interview.

RESULTS

White matter damage was common (present on CT in 77%) and severe (advanced CT grade in 32%). White matter damage was correlated with the total number of hemorrhages on gradient-echo MRI and with risk of recurrent ICH. Subjects with cognitive impairment prior to their index ICH were more likely to have severe white matter damage on CT (OR 3.6, 95% CI 1.6 to 8.1, p = 0.003) and more likely to have advanced periventricular hyperintensities on MRI. The relationships between white matter damage and cognitive impairment were similar in the subset of 88 subjects meeting criteria for probable or definite cerebral amyloid angiopathy and remained independent after adjustment for age, cortical atrophy, and APOE genotype.

CONCLUSIONS

White matter damage in lobar ICH is common and is associated with cognitive impairment. These data support the possibility that an underlying vasculopathy in lobar ICH patients, possibly cerebral amyloid angiopathy, can cause clinically important vascular dysfunction.

Size-dependent feeding and reproduction by boll weevil (Coleoptera: Curculionidae)

The considerable variation in adult size of the boll weevil, Anthonomus grandis grandis Boheman, has been well documented, but the influences of adult size on reproductive rate are not known. We examined the relationship between the size of boll weevils and their feeding and oviposition. Weevils weighed to the nearest milligram were grouped into five categories based on pupal weight: < or =5, 6-10, 11-15, 16-20, and >20 mg. Numbers of lifetime punctures produced in flower buds (squares) of cotton, Gossypium hirsutum L., by both sexes of adults tended to increase with pupal weight. Boll weevil females with pupal weights >10 mg produced progeny with significantly higher survival to adulthood and also produced a higher percentage of female progeny than those with pupal weights < or =10 mg. The population growth indices for females having pupal weights >10 mg averaged 1.8-fold higher than those of females weighing < or =10 mg. Survivorship of adults of both sexes also tended to increase with pupal weight. The percentage of females laying eggs on any given day averaged 2.1 times higher when their pupal weights were >10 mg than when their pupal weights were < or =10 mg. Although small size negatively affected female reproductive potential, even extremely small females produced some viable offspring. However, the penalties of small adult size, in terms of longevity and reproductive potential, suggest that cultural practices that result in the production of small adults may be used to impact weevil populations.

Effects of planting dates on boll weevils (Coleoptera: Curculionidae) and cotton fruit in the subtropics

The effects of planting dates 2-3-wk apart on boll weevil, Anthonomus grandis grandis Boheman (Coleoptera: Curculionidae), field-level populations, and feeding and oviposition damage to cotton, Gossypium hirsutum L., squares and bolls, were studied during 2002 and 2003 in the Lower Rio Grande Valley of Texas. Squares were 44-56% more abundant in some later planted treatments than in the earlier planted treatments, but mean cumulative numbers of oviposition- and feeding-damaged squares were 2.7 - 4.8-fold greater in some later planted treatments than in earlier treatments. Increased square production in later planted cotton was offset by boll weevil infestations that occurred when squares are most vulnerable and contribute most toward the pest's reproduction. Early planting avoided boll weevil population buildups in the field when large squares were abundant. Lint yields in 2002 did not differ significantly between the planting date treatments, but in 2003, mean yield in the middle treatment was 23% greater than in the early and late-planted treatments. Insecticide sprays in the earliest planted treatment of each year, based on the 10% damaged squares threshold, were >33% and >43% fewer than in the corresponding middle and latest planting treatments, respectively. Delayed planting, relative to the onset of favorable cotton-growing weather, at the field level, even when not applied uniformly on an areawide scale, is more cost-effective than planting too early or too late.

Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage

BACKGROUND

Warfarin increases mortality of intracerebral hemorrhage (ICH). The authors investigated whether this effect reflects increased baseline ICH volume at presentation or increased ICH expansion.

METHODS

Subjects were drawn from an ongoing prospective cohort study of ICH outcome. The effect of warfarin on baseline ICH volume was studied in 183 consecutive cases of supratentorial ICH age > or = 18 years admitted to the emergency department over a 5-year period. Baseline ICH volume was determined using computerized volumetric analysis. The effect of warfarin on ICH expansion (increase in volume > or = 33% of baseline) was analyzed in 70 consecutive cases in whom ICH volumes were measured on all subsequent CT scans up to 7 days after admission. Multivariable analysis was used to determine warfarin's influence on baseline ICH, ICH expansion, and whether warfarin's effect on ICH mortality was dependent on baseline volume or subsequent expansion.

RESULTS

There was no effect of warfarin on initial volume. Predictors of larger baseline volume were hyperglycemia (p < 0.0001) and lobar hemorrhage (p < 0.0001). Warfarin patients were at increased risk of death, even when controlling for ICH volume at presentation. Warfarin was the sole predictor of expansion (OR 6.2, 95% CI 1.7 to 22.9) and expansion in warfarin patients was detected later in the hospital course compared with non-warfarin patients (p < 0.001). ICH expansion showed a trend toward increased mortality (OR 3.5, 95% CI 0.7 to 8.9, p = 0.14) and reduced the marginal effect of warfarin on ICH mortality.

CONCLUSIONS

Warfarin did not increase ICH volume at presentation but did raise the risk of in-hospital hematoma expansion. This expansion appears to mediate part of warfarin's effect on ICH mortality.

Effects of burial and soil condition on postharvest mortality of boll Weevils (Coleoptera: Curculionidae) in fallen cotton fruit

Effects of soil condition and burial on boll weevil, Anthonomus grandis grandis Boheman, mortality in fallen cotton, Gossypium hirsutum L., fruit were assessed in this study. During hot weather immediately after summer harvest operations in the Lower Rio Grande Valley of Texas, burial of infested fruit in conventionally tilled field plots permitted significantly greater survival of weevils than in no-tillage plots. Burial of infested squares protected developing weevils from heat and desiccation that cause high mortality on the soil surface during and after harvest in midsummer and late summer. A laboratory assay showed that burial of infested squares resulted in significantly greater weevil mortality in wet than in dry sandy or clay soils. Significantly fewer weevils rose to the soil surface after burial of infested bolls during winter compared with bolls set on the soil surface, a likely result of wetting by winter rainfall. A combination of leaving infested fruit exposed to heat before the onset of cooler winter temperatures and burial by tillage when temperatures begin to cool might be an important tactic for reducing populations of boll weevils that overwinter in cotton fields.

Deterrent effects of four neem-based formulations on gravid female boll weevil (Coleoptera: Curculionidae) feeding and oviposition on cotton squares

Three commercial neem-based insecticides, Agroneem, Ecozin, and Neemix, and a neem seed extract formulation, bitters, containing 1,036, 16,506, 471, and 223 microg/ml azadirachtin, respectively, were assessed for feeding and oviposition deterrence against gravid female boll weevils, Anthonomus grandis grandis Boheman, in the laboratory. In choice assays, excised cotton squares dipped in the separate formulations were first physically contacted by the weevils' tarsi or antennae fewer times than nontreated control squares. In choice and no-choice assays, each formulation repelled the weevils for > or = 90 min. After 24 h in the choice assays, feeding punctures on the squares treated with Agroneem, Ecozin, or bitters were significantly fewer compared with controls. Egg punctures on the Ecozin- and the bitters-treated squares were significantly fewer than on control squares after 24 h. In the no-choice assay, no significant difference was detected. Aging the formulations under outdoor conditions for 24 h before weevils were exposed resulted in 46-60% and 62-82% reductions in feeding and oviposition punctures, respectively, compared with controls. Agroneem- and bitters-treated squares had > 37% fewer feeding punctures after being aged for 48 h. No significant difference was detected after 72 h of aging. Because the deterrence of the gravid female boll weevils was not correlated with amounts of azadirachtin, azadirachtin does not seem to be the only, or the most influential, component of neem that induced the observed deterrence.

Hemorrhagic stroke associated with the Iowa amyloid precursor protein mutation

The authors searched for mutations in the beta-amyloid precursor protein in a Spanish family with a hereditary syndrome of hemorrhagic stroke, dementia, leukoencephalopathy, and occipital calcifications. DNA from two affected members demonstrated the Iowa amyloid precursor protein mutation previously identified as a cause of severe amyloid angiopathy without hemorrhagic stroke. These data point to other genetic or environmental factors that may determine the occurrence of symptomatic hemorrhage in amyloid angiopathy.

Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke

BACKGROUND AND OBJECTIVES

Prior ischemic stroke is a risk factor for intracerebral hemorrhage (ICH) in patients taking warfarin, but the mechanism is not known. This study investigates radiographic and clinical characteristics of patients with warfarin-related ICH following ischemic stroke.

METHODS

In this case-control study, the authors selected all patients with warfarin-related ICH and previous symptomatic ischemic stroke from a prospective cohort of consecutive patients with ICH. Control subjects were similarly aged patients with history of symptomatic stroke randomly chosen from an anticoagulant therapy unit. The 26 eligible ICH cases and 56 controls were compared for vascular risk factors, stroke characteristics, and extent of leukoaraiosis (graded in anterior and posterior brain regions on a validated scale of 0 to 4).

RESULTS

The presence and severity of leukoaraiosis on CT scan correlated strongly with the occurrence of ICH. Leukoaraiosis was seen in 24 of 26 cases (92%) compared with 27 of 56 controls (48%), yielding an odds ratio of 12.9 (95% CI 2.8 to 59.8). Other clinical factors associated with ICH included an international normalized ratio >3.0, history of multiple previous strokes, and the presence of carotid artery stenosis. The relationship between leukoaraiosis and ICH persisted in multivariable analyses controlling for these risk factors as well as hypertension and diabetes mellitus.

CONCLUSIONS

Leukoaraiosis is an independent risk factor for warfarin-related ICH in survivors of ischemic stroke, including those in the commonly employed range of anticoagulation.

Pathogenic effects of D23N Iowa mutant amyloid beta -protein

Cerebral amyloid beta-protein angiopathy (CAA) is a key pathological feature of patients with Alzheimer's disease and certain related disorders. In these conditions the CAA is characterized by the deposition of Abeta within the cerebral vessel wall and, in severe cases, hemorrhagic stroke. Several mutations have been identified within the Abeta region of the Abeta protein precursor (AbetaPP) gene that appear to enhance the severity of CAA. We recently described a new mutation within the Abeta region (D23N) of AbetaPP that is associated with severe CAA in an Iowa kindred (Grabowski, T. J., Cho, H. S., Vonsattel, J. P. G., Rebeck, G. W., and Greenberg, S. M. (2001) Ann. Neurol. 49, 697-705). In the present study, we investigated the effect of this new D23N mutation on the processing of AbetaPP and the pathogenic properties of Abeta. Neither the D23N Iowa mutation nor the E22Q Dutch mutation affected the amyloidogenic processing of AbetaPP expressed in H4 cells. The A21G Flemish mutation, in contrast, resulted in a 2.3-fold increase in secreted Abeta peptide. We also tested synthetic wild-type and mutant Abeta40 peptides for fibrillogenesis and toxicity toward cultured human cerebrovascular smooth muscle (HCSM) cells. The E22Q Dutch, D23N Iowa, and E22Q,D23N Dutch/Iowa double mutant Abeta40 peptides rapidly assembled in solution to form fibrils, whereas wild-type and A21G Flemish Abeta40 peptides exhibited little fibril formation. Similarly, the E22Q Dutch and D23N Iowa Abeta40 peptides were found to induce robust pathologic responses in cultured HCSM cells, including elevated levels of cell-associated AbetaPP, proteolytic breakdown of smooth muscle cell alpha-actin, and cell death. Double mutant E22Q,D23N Dutch/Iowa Abeta40 was more potent than either single mutant form of Abeta in causing pathologic responses in HCSM cells. These data suggest that the different CAA mutations in AbetaPP may exert their pathogenic effects through different mechanisms. Whereas the A21G Flemish mutation appears to enhance Abeta production, the E22Q Dutch and D23N Iowa mutations enhance fibrillogenesis and the pathogenicity of Abeta toward HCSM cells.

The effects of AbetaPP mutations and APOE polymorphisms on cerebral amyloid angiopathy

Analysis of causative mutations and genetic risk factors aid in the understanding of important processes of cerebral amyloid angiopathy (CAA) in humans. We identified a mutation at a novel site of the beta-amyloid precursor protein (AbetaPP) gene associated with familial CAA; this mutation causes an aspartate to asparagine substitution at position 23 of the Abeta peptide. Neuropathological analysis of a 68-year-old man with this mutation showed dramatic Abeta deposition in blood vessels, diffiuse parenchymal Abeta deposits, dystrophic neurites and neurofibrillary tangles. The Abeta deposition showed complete co-localization of Abeta40 and Abeta42, compared to the predominant Abeta42 deposition seen in AD. We hypothesize that the loss of an acidic residue at position 23 of Abeta might be important in the process of Abeta aggregation on smooth muscle cells on the cerebrovasculature. We also analyzed how the apolipoprotein E (APOE) gene might influence aggregation of Abeta by examining the physical association of apoE domains with Abeta via immunohistochemistry. We found that the lipid-binding domain of apoE was more strongly associated with Abeta than the receptor-binding domain, and that 40% of all Abeta deposits had no apoE bound to them. We suggest that the initial deposition of Abeta occurs in the absence of apoE, and that the process of Abeta deposit growth or stabilization is apoE-dependent.

Outcome markers for clinical trials in cerebral amyloid angiopathy

Determining the effectiveness of candidate treatments for preventing hemorrhagic strokes caused by cerebral amyloid angiopathy will require clinical drug trials. This article explores tvo potential outcome markers for such trials: (1) clinical recurrence of hemorrhagic stroke, and (2) the appearance of small, clinically silent hemorrhagic lesions on gradient-echo MRI. Using pilot data from our cohort of survivors of lobar hemorrhage, we estimated the sample sizes required to demonstrate efficacy with each of these outcome markers as the study endpoint. A study with recurrent hemorrhagic stroke as the endpoint was estimated to require 145 patients per treatment arm to demonstrate a 50% reduction in the recurrence rate over a 24-month follow-up period, while a study using new hemorrhagic lesions on MRI was estimated to require 70 patients per arm for a 17-month follow-up interval. The required sample sizes could be further reduced (to 105 and 52 patients, respectively) by limiting the analysis to those at highest risk of recurrence, defined according to apolipoprotein E genotype or the presence of more than one hemorrhagic lesion at study entry. This analysis suggests that radiographic detection of small hemorrhages may be an efficient surrogate endpoint for pilot trials of promising therapeutic approaches to cerebral amyloid angiopathy.

Novel amyloid precursor protein mutation in an Iowa family with dementia and severe cerebral amyloid angiopathy

Several mutations in the amyloid precursor protein (APP) gene have been found to associate with pathologic deposition of the beta-amyloid peptide (Abeta) in neuritic plaques or in the walls of cerebral vessels. We report a mutation at a novel site in APP in a three-generation Iowa family with autosomal dominant dementia beginning in the sixth or seventh decade of life. The proband and an affected brother had progressive aphasic dementia, leukoencephalopathy, and occipital calcifications. Neuropathological examination of the proband revealed severe cerebral amyloid angiopathy, widespread neurofibrillary tangles, and unusually extensive distribution of Abeta40 in plaques. The affected brothers shared a missense mutation in APP, resulting in substitution of asparagine for aspartic acid at position 694. This site corresponds to residue 23 of Abeta, thus differing from familial Alzheimer's disease mutations, which occur outside the Abeta sequence. Restriction enzyme analysis of DNA from 94 unrelated patients with sporadic cerebral amyloid angiopathy-related hemorrhage found no other instances of this mutation. These results suggest a novel site within Abeta that may promote its deposition and toxicity.

Quantitation of apoE domains in Alzheimer disease brain suggests a role for apoE in Abeta aggregation

Apolipoprotein E (apoE) and apoE-derived proteolytic fragments are present in amyloid deposits in Alzheimer disease (AD) and cerebral amyloid angiopathy (CAA). In this study, we examined which apoE fragments are most strongly associated with amyloid deposits and whether apoE receptor binding domains were present. We found that both apoE2- and apoE4-specific residues were present on plaques and blood vessels in AD and CAA. We quantified Abeta plaque burden and apoE plaque burdens in 5 AD brains. ApoE N-terminal-specific and C-terminal-specific antibodies covered 50% and 74% of Abeta plaque burden, respectively (p < 0.003). Double-labeling demonstrated that the plaque cores contained the entire apoE protein, but that outer regions contained only a C-terminal fragment, suggesting a cleavage in the random coil region of apoE. Presence of N- and C-terminal apoE cleavage fragments in brain extracts was confirmed by immunoblotting. The numbers of plaques identified by the apoE N-terminal-specific antibodies and the apoE C-terminal-specific antibody were equal, but were only approximately 60% of the total Abeta plaque number (p < 0.0001). Analysis of the size distribution of Abeta and apoE deposits demonstrated that most of the Abeta-positive, apoE-negative deposits were the smallest deposits (less than 150 microm2). These data suggest that C-terminal residues of apoE bind to Abeta and that apoE may help aid in the progression of small Abeta deposits to larger deposits. Furthermore, the presence of the apoE receptor binding domain in the center of amyloid deposits could affect surrounding cells via chronic interactions with cell surface apoE receptors.

Clinical diagnosis of cerebral amyloid angiopathy: validation of the Boston criteria

The authors performed clinical-pathologic correlation to assess the validity of the Boston diagnostic criteria for cerebral amyloid angiopathy (CAA). Thirteen subjects were diagnosed clinically with probable CAA from among 39 patients with available pathologic tissue in a prospective cohort of subjects aged > or = 55 years with primary lobar hemorrhage. All 13 individuals were confirmed neuropathologically as having CAA. This small pathologic series indicates that the diagnosis of probable CAA can be made during life with high accuracy.

Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study

BACKGROUND

Intracerebral hemorrhage (ICH) is the most feared complication of warfarin therapy. The pathogenesis of this often-fatal complication remains obscure. Cerebral amyloid angiopathy (CAA) is a major cause of spontaneous lobar hemorrhage in the elderly and is associated with specific alleles of the APOE gene.

OBJECTIVE

To assess the role of CAA in warfarin-associated ICH.

METHODS

Clinical characteristics and APOE genotype were compared between 41 patients with warfarin-related ICH (from a cohort of 59 consecutive patients aged > or = 65 years with supratentorial ICH on warfarin) and 66 randomly selected individuals aged > or = 65 years without ICH taking warfarin. In addition, all neuropathologic specimens from ICH patients were reviewed for the presence and severity of CAA.

RESULTS

Hemorrhages tended to be in the lobar regions of the brain, and most (76%) occurred with an international normalized ratio of < or = 3.0. The APOE epsilon2 allele was overrepresented among patients with warfarin-associated lobar hemorrhage (allele frequency 0.13 versus 0.04 in control subjects; p = 0.031). After controlling for other variables associated with ICH, carriers of the epsilon2 allele had an OR of 3.8 (95% CI, 1.0 to 14.6) for lobar ICH. CAA was pathologically diagnosed as the cause of lobar hemorrhage in 7 of 11 patients with available tissue samples.

CONCLUSIONS

CAA is an important cause of warfarin-associated lobar ICH in the elderly. Although diagnosis of CAA before hemorrhage is not yet possible, these data offer hope that future patients at high risk for hemorrhage may be identified before initiation of warfarin therapy.

Plasma beta-amyloid peptide, transforming growth factor-beta 1, and risk for cerebral amyloid angiopathy

Despite the documented association between apolipoprotein E genotype and cerebral amyloid angiopathy (CAA), a substantial proportion of CAA-related hemorrhages occur in patients without known risks for this disorder. Two other factors implicated in the pathogenesis of CAA are the amyloid-beta peptide (preferentially deposited in vessels as a 40-amino acid species) and the multifunctional cytokine transforming growth factor-beta 1 (a specific promoter of vascular amyloid deposition in transgenic models). We measured plasma concentrations of these factors in a series of 25 patients diagnosed with probable or definite CAA-related hemorrhage and compared them with 21 patients with hemorrhage due to probable hypertensive vasculopathy and 42 elderly control subjects without hemorrhage. We found no differences among the groups in concentrations of the 40- or 42-amino acid species of beta-amyloid or either the active or latent form of transforming growth factor-beta 1. While the data do not exclude important roles for these molecules as risks for CAA, they indicate that plasma measurements are not useful in its diagnosis.

Apolipoprotein E genotype and the risk of recurrent lobar intracerebral hemorrhage

BACKGROUND

Recurrent lobar intracerebral hemorrhage is the hallmark of cerebral amyloid angiopathy. The factors that predispose patients to early recurrence of lobar hemorrhage are unknown. One candidate is the apolipoprotein E gene, since both the epsilon2 and the epsilon4 alleles of apolipoprotein E appear to be associated with the severity of amyloid angiopathy.

METHODS

We performed a prospective, longitudinal study of consecutive elderly patients who survived a lobar intracerebral hemorrhage. The patients were followed for recurrent hemorrhagic stroke by interviews at six-month intervals and reviews of medical records and computed tomographic scans.

RESULTS

Nineteen of 71 enrolled patients had recurrent hemorrhages during a mean follow-up period of 23.9+/-14.8 months, yielding a 2-year cumulative rate of recurrence of 21 percent. The apolipoprotein E genotype was significantly associated with the risk of recurrence. Carriers of the epsilon2 or epsilon4 allele had a two-year rate of recurrence of 28 percent, as compared with only 10 percent for patients with the common apolipoprotein E epsilon3/epsilon3 genotype (risk ratio, 3.8; 95 percent confidence interval, 1.2 to 11.6; P=0.01). Early recurrence occurred in eight patients, four of whom had the uncommon epsilon2/epsilon4 genotype. Also at increased risk for recurrence were patients with a history of hemorrhagic stroke before entry into the study (two-year recurrence, 61 percent; risk ratio, 6.4; 95 percent confidence interval, 2.2 to 18.5; P<0.001).

CONCLUSIONS

The apolipoprotein E genotype can identify patients with lobar intracerebral hemorrhage who are at highest risk for early recurrence. This finding makes possible both the provision of prognostic information to patients with lobar hemorrhage and a method of targeting and assessing potential strategies for prevention.

Donepezil therapy in clinical practice: a randomized crossover study

OBJECTIVE

To determine the efficacy of donepezil hydrochloride for the treatment of Alzheimer disease in patients drawn from clinical practice.

DESIGN

Two-center, randomized, placebo-controlled, double-masked crossover study.

SETTING

Memory disorders units at Massachusetts General and Brigham and Women's hospitals, Boston.

PATIENTS

Sixty individuals (30 men and 30 women; mean +/- SD age, 75.0+/-9.5 years) with probable Alzheimer disease and scores of 20 or less on the information-memory-concentration subscale of the Blessed Dementia Scale.

INTERVENTIONS

Placebo wash-in, followed in randomized sequence by (1) donepezil hydrochloride therapy, 5 mg/d, for 6 weeks, followed by placebo washout for 6 weeks and (2) placebo treatment for 6 weeks.

PRIMARY OUTCOME MEASURE

Change in Alzheimer's Disease Assessment Scale cognitive subscale scores from the beginning to the end of the two 6-week treatment periods.

RESULTS

Among patients completing treatment and testing for both periods (n = 48), subscale scores improved (mean +/- SEM) 2.17+/-0.98 points (95% confidence interval, 0.20-4.10 points) during donepezil therapy relative to placebo therapy (P = .04). Scores returned toward baseline within 3 weeks of drug washout. There was no associated change in caregiver-rated global impression (donepezil vs placebo: proportion improved, 0.24 vs 0.22; proportion worsened, 0.27 vs 0.35; P = .34) or on specific tests of explicit memory or verbal fluency. Contrary to studies with tacrine, the presence of the apolipoprotein E epsilon4 allele did not predict donepezil treatment failure. Most common adverse events related to donepezil therapy were nausea (5 patients), diarrhea (3 patients), and agitation (3 patients). Serious events possibly related to drug use were seizure, pancreatitis, and syncope (1 patient each).

CONCLUSION

This independent confirmation of data from phase 3 trials suggests that donepezil therapy modestly improves cognition in patients with Alzheimer disease who are encountered in clinical practice.

MRI detection of new hemorrhages: potential marker of progression in cerebral amyloid angiopathy

The authors used serial gradient-echo MRIs to detect new small hemorrhages in patients with previous lobar hemorrhage. Of 24 lobar hemorrhage patients (17 diagnosed with probable and 7 with possible amyloid angiopathy) who prospectively underwent repeat MRI 1.5 years after initial study, 9 (38%) demonstrated additional hemorrhages at follow-up. Interrater agreement was high. New hemorrhages were more frequent in patients with probable amyloid angiopathy (8 of 17, 47%) with more hemorrhages at baseline (p < 0.01). These results suggest a role for gradient-echo MRI in assessing disease progression in amyloid angiopathy.