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Zúñiga D, Zúñiga G, Hincapié S, Salazar E. Cerebral Amyloid Angiopathy-Related Inflammation (CAA-ri): Presentation at an Unusual Age. Cureus 2023; 15:e42454. [PMID: 37637532 PMCID: PMC10457129 DOI: 10.7759/cureus.42454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a less common but aggressive manifestation of CAA caused by an autoimmune reaction to the amyloid-beta (Ab) deposits in affected vessels. Here, we report the case of a 96-year-old patient, with a history of Alzheimer's disease, who presented to our hospital due to a sudden onset of high-intensity holocranial headache followed by dysarthria, left hemiplegia, and gaze deviation to the right. MRI of the brain was performed, which revealed a heterogeneous hypointense signal on the right frontal T2 and fluid-attenuated inversion recovery (FLAIR) sequences, with an asymmetric hyperintensity surrounding the lesion compatible with perilesional vasogenic edema. Given the clinical radiographic findings, a diagnosis of CAA-ri was established and immediate treatment with intravenous corticosteroids was started, with a rapid clinical response and remarkable improvement in follow-up neuroimaging.
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Affiliation(s)
- Diego Zúñiga
- Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Gabriel Zúñiga
- Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Sofía Hincapié
- Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Erin Salazar
- Neurology, Hospital Luis Vernaza, Guayaquil, ECU
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Corovic A, Kelly S, Markus HS. Cerebral amyloid angiopathy associated with inflammation: A systematic review of clinical and imaging features and outcome. Int J Stroke 2017; 13:257-267. [DOI: 10.1177/1747493017741569] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Cerebral amyloid angiopathy associated with inflammation is an increasingly recognized condition, characterized by an inflammatory response to the vascular deposits of β-amyloid within the brain that are the hallmark of cerebral amyloid angiopathy. Two main patterns of this inflammatory response have been identified to date: one involving a perivascular inflammatory cell infiltrate (cerebral amyloid angiopathy-related inflammation); the other a transmural vasculitic process (A-beta related angiitis). Unlike cerebral amyloid angiopathy itself, which predisposes to intracerebral hemorrhage and has no known treatment, cerebral amyloid angiopathy associated with inflammation typically presents in diverse ways and diagnosis may be challenging and delayed. Aims We sought to summarize the clinical features, imaging appearances and available data on outcome and treatment responses, using information derived from a systematic review of pathologically proven cases of cerebral amyloid angiopathy associated with inflammation. Summary of review We identified 213 distinct pathologically proven cases of cerebral amyloid angiopathy-related inflammation/A-beta related angiitis, from 104 publications. The clinical presentation, imaging features, pathology, treatment, and outcomes of cerebral amyloid angiopathy associated with inflammation are described. Conclusions Cerebral amyloid angiopathy associated with inflammation is an important and increasingly recognized clinical condition, which affects the older patient population and presents most commonly with cognitive decline, seizures, and headaches. Future research is required to develop and validate diagnostic criteria and determine optimum treatment strategies.
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Affiliation(s)
- Andrej Corovic
- Department of Stroke Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Siobhan Kelly
- Department of Stroke Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Hugh S Markus
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
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Chu S, Xu F, Su Y, Chen H, Cheng X. Cerebral Amyloid Angiopathy (CAA)-Related Inflammation: Comparison of Inflammatory CAA and Amyloid-β-Related Angiitis. J Alzheimers Dis 2016; 51:525-32. [PMID: 26890776 DOI: 10.3233/jad-151036] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Shuguang Chu
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Feijia Xu
- Department of Radiology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| | - Ya Su
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Hong Chen
- Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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Mendonça MD, Caetano A, Pinto M, Cruz e Silva V, Viana-Baptista M. Stroke-Like Episodes Heralding a Reversible Encephalopathy: Microbleeds as the Key to the Diagnosis of Cerebral Amyloid Angiopathy–Related Inflammation—A Case Report and Literature Review. J Stroke Cerebrovasc Dis 2015; 24:e245-50. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/02/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022] Open
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Castro Caldas A, Silva C, Albuquerque L, Pimentel J, Silva V, Ferro JM. Cerebral Amyloid Angiopathy Associated with Inflammation: Report of 3 Cases and Systematic Review. J Stroke Cerebrovasc Dis 2015; 24:2039-48. [PMID: 26163888 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 03/20/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Cerebral amyloid angiopathy associated with inflammatory process (CAA-I) is a rare potentially treatable encephalopathy, characterized by an inflammatory response to vascular deposits of β-amyloid. We aimed to describe 3 clinical cases and perform a systematic review of all neuropathologically proved CAA-I case reports to describe its clinical and pathologic features and outcome under different treatments. METHODS We searched PubMed and Cochrane Library and screened references of included studies and review articles for additional citations. Outcome was classified at the last available follow-up by the modified Rankin Scale (mRS). RESULTS A total of 67 publications, reporting on 155 patients, were included. Mean age was 66.9 years, and 53.5% were men. The most common clinical presentation was cognitive dysfunction (48.0%) followed by headaches (38.7%), seizures (36.7%), and pyramidal signs (20.0%). Perivascular and vasculitic inflammation with granuloma was the most common pathologic pattern (27.5%). Eighty-six percent were treated with corticosteroids and 33.9% with cyclophosphamide. Forty-two percent regained independence (mRS score 0-2), whereas 20.5% were left with a severe handicap (mRS score 3-5) and 37.5% died. There were no statistically significant differences in outcome between patients treated with therapy with corticosteroids alone comparing with those treated with combination corticosteroids with cytostatic agents. CONCLUSIONS The most common clinical manifestation of CAA-I was cognitive dysfunction. The functional outcome was unfavorable in the majority of the patients, with death or severe disability in almost two third of the cases, despite treatment. No differences in outcome could be detected between patients treated with corticosteroids versus patients treated with cytostatics, combined with corticosteroids.
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Affiliation(s)
- Ana Castro Caldas
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.
| | - Cristiana Silva
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Luísa Albuquerque
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal
| | - José Pimentel
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal; Laboratory of Neuropathology, Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal
| | - Vanessa Silva
- Serviço de Neurologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - José Manuel Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal
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Danve A, Grafe M, Deodhar A. Amyloid Beta-Related Angiitis—A Case Report and Comprehensive Review of Literature of 94 Cases. Semin Arthritis Rheum 2014; 44:86-92. [DOI: 10.1016/j.semarthrit.2014.02.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/27/2014] [Accepted: 02/07/2014] [Indexed: 11/30/2022]
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Abstract
The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.
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Affiliation(s)
- Harold P Adams
- Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa Health Care Stroke Center, University of Iowa, Iowa City, IA, USA.
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Omisade A, Rigby H, Easton A, Phillips SJ, Carter SL. Longitudinal neuropsychological findings in amyloid beta-related angiitis (AβRA): A case report. Clin Neuropsychol 2012; 27:300-12. [DOI: 10.1080/13854046.2012.744851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Antonina Omisade
- a Psychology, QEII Health Sciences Centre , Halifax , NS , Canada
| | - Heather Rigby
- b Division of Neurology , Dalhousie University , Halifax , NS , Canada
| | - Alexander Easton
- c Department of Pathology , Dalhousie University , Halifax , NS , Canada
| | | | - Sherri L. Carter
- a Psychology, QEII Health Sciences Centre , Halifax , NS , Canada
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Sakai K, Hayashi S, Sanpei K, Yamada M, Takahashi H. Multiple cerebral infarcts with a few vasculitic lesions in the chronic stage of cerebral amyloid angiopathy-related inflammation. Neuropathology 2011; 32:551-6. [DOI: 10.1111/j.1440-1789.2011.01283.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Salvarani C, Brown RD, Calamia KT, Christianson TJH, Huston J, Meschia JF, Giannini C, Miller DV, Hunder GG. Primary central nervous system vasculitis presenting with intracranial hemorrhage. ACTA ACUST UNITED AC 2011; 63:3598-606. [PMID: 22038406 DOI: 10.1002/art.30594] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sakaguchi H, Ueda A, Kosaka T, Yamashita S, Kimura E, Yamashita T, Maeda Y, Hirano T, Uchino M. Cerebral amyloid angiopathy-related inflammation presenting with steroid-responsive higher brain dysfunction: case report and review of the literature. J Neuroinflammation 2011; 8:116. [PMID: 21914214 PMCID: PMC3185269 DOI: 10.1186/1742-2094-8-116] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 09/14/2011] [Indexed: 11/10/2022] Open
Abstract
A 56-year-old man noticed discomfort in his left lower limb, followed by convulsion and numbness in the same area. Magnetic resonance imaging (MRI) showed white matter lesions in the right parietal lobe accompanied by leptomeningeal or leptomeningeal and cortical post-contrast enhancement along the parietal sulci. The patient also exhibited higher brain dysfunction corresponding with the lesions on MRI. Histological pathology disclosed β-amyloid in the blood vessels and perivascular inflammation, which highlights the diagnosis of cerebral amyloid angiopathy (CAA)-related inflammation. Pulse steroid therapy was so effective that clinical and radiological findings immediately improved.CAA-related inflammation is a rare disease, defined by the deposition of amyloid proteins within the leptomeningeal and cortical arteries associated with vasculitis or perivasculitis. Here we report a patient with CAA-related inflammation who showed higher brain dysfunction that improved with steroid therapy. In cases with atypical radiological lesions like our case, cerebral biopsy with histological confirmation remains necessary for an accurate diagnosis.
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Affiliation(s)
- Hideya Sakaguchi
- Department of Neurology, Faculty of Life Sciences, Kumamoto University 1-1-1 Honjo, Kumamoto 860-0811, Japan.
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Prevalence of asymptomatic vasogenic edema in pretreatment Alzheimer's disease study cohorts from phase 3 trials of semagacestat and solanezumab. Alzheimers Dement 2011; 7:396-401. [DOI: 10.1016/j.jalz.2011.05.2353] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 05/12/2011] [Accepted: 05/17/2011] [Indexed: 11/18/2022]
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