The incidence of cerebral amyloid angiopathy in surgically treated intracranial hemorrhage in the Chinese population

SMASH-U aetiological classification: A predictor of long-term functional outcome after intracerebral haemorrhage

BACKGROUND

SMASH-U is a systematic aetiological classification system for intracerebral haemorrhage (ICH) proven to be a predictor of post-ICH haematoma expansion and mortality. However, its role in predicting functional outcome remains elusive. Therefore, we aimed to investigate whether SMASH-U is associated with long-term functional outcome after ICH and improves the accuracy of prediction when added to max-ICH score.

METHODS

Consecutive acute ICH patients from 2012 to 2018 from the neurology department of Tongji Hospital were enrolled. ICH aetiology was classified according to the SMASH-U system. The association of SMASH-U with 12-month functional outcome after ICH and the predictive value were evaluated.

RESULTS

Of 1938 ICH patients, the aetiology of 1295 (66.8%) patients were classified as hypertension, followed by amyloid angiopathy (n = 250, 12.9%), undetermined (n = 159, 8.2%), structural lesions (n = 149, 7.7%), systemic disease (n = 74, 3.8%) and medication (n = 11, 0.6%). The baseline characteristics were different among the six aetiologies. In multivariate analysis, SMASH-U was proven to be a predictor of 12-month unfavourable functional outcome. When adding the SMASH-U system, the predictive performance of max-ICH score was improved (area under the receiver operating characteristic curve from 0.802 to 0.812, p = 0.010) and the predictive accuracy was enhanced (integrated discrimination improvement [IDI]: 1.60%, p < 0.001; continuous net reclassification improvement [NRI]: 28.16%, p < 0.001; categorical NRI: 3.34%, p = 0.004).

CONCLUSIONS

SMASH-U predicted long-term unfavourable functional outcomes after acute ICH and improved the accuracy of prediction when added to max-ICH score. Integrating the aetiology to a score model to predict the post-ICH outcome may be meaningful and worthy of further exploration.

Superficial Cerebellar Microbleeds and Cerebral Amyloid Angiopathy

Background and Purpose—

The differentiation between cerebral amyloid angiopathy (CAA) and hypertensive small vessel disease in primary intracerebral hemorrhage is mainly based on hemorrhagic neuroimaging markers in the supratentorial regions, and the cause for cerebellar microbleeds remains unknown. Our aim was to investigate whether superficial cerebellar microbleeds are more likely to be related to CAA rather than hypertensive small vessel disease.

Methods—

Two hundred seventy-five consecutive patients with intracerebral hemorrhage were retrospectively reviewed from a prospectively maintained hospital-based stroke registry. Eighty-five (33.1%) patients had cerebellar microbleeds and were categorized into superficial (gray matter, vermis), deep (white matter, deep nucleus, cerebellar peduncle), or mixed type based on the location of cerebellar hemorrhagic lesions. Amyloid imaging was obtained using 11C-Pittsburgh Compound B–positron emission tomography in a subgroup of patients. The associations between cerebellar microbleed locations and the type of small vessel disease (CAA versus hypertensive small vessel disease) based on distribution of supratentorial hemorrhagic lesions as well as other magnetic resonance imaging and positron emission tomography markers were analyzed.

Results—

The presence of cerebellar microbleed was independently associated with supratentorial microbleed and lacunar infarcts (both P <0.01). Strictly superficial cerebellar microbleeds were significantly related to CAA–intracerebral hemorrhage, cortical superficial siderosis and high-grade enlarged perivascular space in centrum semiovale (all P <0.05); deep or mixed cerebellar microbleeds were related to hypertension and deep microbleed (all P <0.05). In multivariable models, superficial cerebellar microbleeds were independently associated with CAA–intracerebral hemorrhage ( P =0.03). Of 33 patients assessed by amyloid positron emission tomography, cerebral and cerebellar amyloid load (standardized uptake value ratio) was higher in patients with superficial cerebellar microbleeds compared with deep/mixed cerebellar microbleeds (cerebrum standardized uptake value ratio [reference: cerebellum] 1.33±0.24 versus 1.05±0.09, P <0.001; cerebellum standardized uptake value ratio [reference: pons] 0.58±0.08 versus 0.51±0.09, P =0.03).

Conclusions—

Patients with strictly superficial cerebellar microbleeds are associated with a clinicoradiological diagnosis of CAA as well as increased cerebral and cerebellar amyloid deposition on Pittsburgh Compound B–positron emission tomography, suggesting underlying CAA pathology.

The etiologic subtype of intracerebral hemorrhage may influence the risk of significant hematoma expansion

BACKGROUND

Intracerebral hemorrhage (ICH) growth is an important independent predictor of clinical deterioration and outcome. Little is known about the association between etiology of ICH and occurrence of hematoma expansion (HE). The aim of the present study was to assess whether ICH etiologic subtype may influence the risk of significant HE.

METHODS

We conducted an analysis on retrospectively collected data of 424 consecutive patients with ICH, who were admitted to the Verona General Hospital, from March 2011 to December 2014. Using the SMASH-U (Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined) classification, we identified the ICH etiologic subtypes. Outcome measure was significant HE (an absolute increase in ICH volume>12.5 mL or >50%) within 48 h.

RESULTS

Significant HE occurred in 11/57 (19.3%) Amyloid, 7/14 (50%) Structural, 31/57 (54.4%) Medication, 25/44 (56.8%) in Systemic, 62/139 (44.6%) Hypertensive, and 21/68 (30.9%) Undetermined ICH. Baseline ICH volume (OR 1.011 per mL, 95% CI 1.006-1.017, p<0.001) and onset-to-baseline CT time (OR 0.919 per hour, 95% CI 0.852-0.990, p=0.027) were predictors of significant HE. Compared with Amyloid ICH, ORs for significant HE were higher in patients with Structural ICH (OR 1.430, 95% CI 1.060-1.948, p=0.023), Medication ICH (OR 4.344, 95% CI 1.382-13.653, p=0.012), Systemic ICH (OR 1.796, 95% CI 1.070-3.015, p=0.027), and Hypertensive ICH (OR 3.081, 95% CI 1.426-6.655, p=0.004).

CONCLUSION

Our study shows that Structural, Medication, Systemic, and Hypertensive ICH were the etiologic subtypes associated with a higher risk of significant HE, compared with Amyloid ICH patients.

Clinical Neuropathological Analysis of 10 Cases of Cerebral Amyloid Angiopathy-Related Cerebral Lobar Hemorrhage

Objective

The clinical and pathological characteristics of 10 cases of cerebral amyloid angiopathy (CAA)-related cerebral lobar hemorrhage (CLH) that was diagnosed at autopsy were investigated to facilitate the diagnosis of this condition.

Methods

The clinical characteristics of 10 cases of CAA-related CLH were retrospectively reviewed, and a neuropathological examination was performed on autopsy samples.

Results

The 10 cases included two with a single lobar hemorrhage and eight with multifocal lobar hemorrhages. In all of the cases, the hemorrhage bled into the subarachnoid space. Pathological examinations of the 10 cases revealed microaneurysms in two, double barrel-like changes in four, multifocal arteriolar clusters in five, obliterative onion skin-like intimal changes in four, fibrinoid necrosis of the vessels in seven, neurofibrillary tangles in eight, and senile plaques in five cases.

Conclusion

CAA-related CLHs were located primarily in the parietal, temporal, and occipital lobes. These hemorrhages normally consisted of multiple repeated CLHs that frequently bled into the subarachnoid space. CAA-associated microvascular lesions may be the pathological factor underlying CLH.

Pathogenetical Subtypes of Recurrent Intracerebral Hemorrhage

Background and Purpose—

Pathogenetic classification of intracerebral hemorrhage (ICH), using systems such as SMASH-U (structural vascular lesions, medication, cerebral amyloid angiopathy [CAA], systemic disease, hypertension, or undetermined), is important in predicting functional outcomes and mortality in patients with ICH. This study aimed to compare pathogenetic subtypes between the first and recurrent ICH.

Methods—

This study obtained data related to 4578 consecutive acute patients with ICH from the National Taiwan University Hospital Stroke Registry during January 1995 to December 2013. Using the SMASH-U method, patients were classified into 6 subtypes. We then analyzed the outcomes of first-ever ICH cases and pathogenetic classification of recurrent ICH.

Results—

Among 3785 patients who experienced first-ever ICH (male, 63.3%; mean age, 58.7±17.0 years), the most common cause was hypertensive angiopathy (54.9%), followed by CAA (12.2%), systemic disease (12.1%), undetermined (10.1%), structural vascular lesions (7.8%), and medication related (2.9%). In 185 cases of recurrent ICH, pathogenetic differences between the 2 ICH events were observed in 34 (18.4%) cases, most of which were CAA to hypertensive angiopathy (n=10) or vice versa (n=7). The rates of ICH recurrence were highest for systemic disease-related and CAA-related ICH at 1, 5, 10, and 15 years after the indexed ICH event.

Conclusions—

In approximately one fifth of the recurrent patients with ICH, pathogenetic differences were observed between initial and recurrent events, particularly among those with CAA. It is possible that some patients with ICH with concomitant hypertensive angiopathy and CAA may have been categorized as CAA by the SMASH-U method.