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Szalardy L, Fakan B, Maszlag-Torok R, Ferencz E, Reisz Z, Radics BL, Csizmadia S, Szpisjak L, Annus A, Zadori D, Kovacs GG, Klivenyi P. Identifying diagnostic and prognostic factors in cerebral amyloid angiopathy-related inflammation: A systematic analysis of published and seven new cases. Neuropathol Appl Neurobiol 2024; 50:e12946. [PMID: 38093468 DOI: 10.1111/nan.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 11/02/2023] [Accepted: 12/05/2023] [Indexed: 02/17/2024]
Abstract
AIMS Cerebral amyloid angiopathy (CAA)-related inflammation (CAA-RI) is a potentially reversible manifestation of CAA, histopathologically characterised by transmural and/or perivascular inflammatory infiltrates. We aimed to identify clinical, radiological and laboratory variables capable of improving or supporting the diagnosis of or predicting/influencing the prognosis of CAA-RI and to retrospectively evaluate different therapeutic approaches. METHODS We present clinical and neuroradiological observations in seven unpublished CAA-RI cases, including neuropathological findings in two definite cases. These cases were included in a systematic analysis of probable/definite CAA-RI cases published in the literature up to 31 December 2021. Descriptive and associative analyses were performed, including a set of clinical, radiological and laboratory variables to predict short-term, 6-month and 1-year outcomes and mortality, first on definite and second on an expanded probable/definite CAA-RI cohort. RESULTS Data on 205 definite and 100 probable cases were analysed. CAA-RI had a younger symptomatic onset than non-inflammatory CAA, without sex preference. Transmural histology was more likely to be associated with the co-localisation of microbleeds with confluent white matter hyperintensities on magnetic resonance imaging (MRI). Incorporating leptomeningeal enhancement and/or sulcal non-nulling on fluid-attenuated inversion recovery (FLAIR) enhanced the sensitivity of the criteria. Cerebrospinal fluid pleocytosis was associated with a decreased probability of clinical improvement and longer term positive outcomes. Future lobar haemorrhage was associated with adverse outcomes, including mortality. Immunosuppression was associated with short-term improvement, with less clear effects on long-term outcomes. The superiority of high-dose over low-dose corticosteroids was not established. CONCLUSIONS This is the largest retrospective associative analysis of published CAA-RI cases and the first to include an expanded probable/definite cohort to identify diagnostic/prognostic markers. We propose points for further crystallisation of the criteria and directions for future prospective studies.
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Affiliation(s)
- Levente Szalardy
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
- Department of Laboratory Medicine and Pathobiology and Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Bernadett Fakan
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Rita Maszlag-Torok
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Emil Ferencz
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Zita Reisz
- Institute of Pathology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
- Department of Clinical Neuropathology, King's College Hospital, London, UK
| | - Bence L Radics
- Institute of Pathology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | | | - Laszlo Szpisjak
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Adam Annus
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Denes Zadori
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Gabor G Kovacs
- Department of Laboratory Medicine and Pathobiology and Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
- Laboratory Medicine Program and Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Peter Klivenyi
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
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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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Oide T, Takahashi H, Yutani C, Ishihara T, Ikeda SI. Relationship between lobar intracerebral hemorrhage and leukoencephalopathy associated with cerebral amyloid angiopathy: clinicopathological study of 64 Japanese patients. Amyloid 2003; 10:136-43. [PMID: 14640026 DOI: 10.3109/13506120308998994] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cerebral amyloid angiopathy (CAA) has two major clinical manifestations: intracerebral hemorrhages and ischemic lesions. Among these, the lobar type of intracerebral hemorrhage (ICH) is a well-known clinical manifestation, while the CAA-related diffuse deep white matter degeneration known as leukoencephalopathy is thought to be rare. The characteristics of CAA-related leukoencephalopathy are still incompletely understood, and the relationship between lobar ICH and leukoencephalopathy in patients with CAA has not been properly clarified. The main purpose of this study is to elucidate the clinical and histopathological features of CAA-related lobar ICH and leukoencephalopathy in order to determine whether the degree of deep white matter degeneration parallels the severity of CAA-associated vasculopathies that lead to vascular wall rupture. We studied 64 Japanese patients with histopathologically proven amyloid beta protein (A beta) type CAA presenting with lobar ICH (52 biopsy and 12 autopsy). In this study, a total of 106 hematomas were observed. CAA-related cerebral hemorrhages tend to occur recurrently and multifocally. Multiple simultaneous labor hemorrhages occasionally developed (9.4%). CAA-related ICH in the sixth decade was not rare (14.1%). Although most patients suffered relapsing and/or multiple severe ICH, no patient in our series presented with diffuse leukoencephalopathy. In conclusion, A beta type cerebrovascular amyloid deposition causes recurrent, multifocal, and often multiple simultaneous ICH even in relatively younger elderly patients, but rarely produces diffuse leukoencephalopathy. This suggests that CAA-associated vasculopathies that cause vascular wall rupture do not always lead to ischemic deep white matter degeneration, and that there may be another unknown pathogenetic mechanism producing the latter CAA-related white matter lesion.
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Affiliation(s)
- Takashi Oide
- Third Department of Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
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Mastaglia FL, Byrnes ML, Johnsen RD, Kakulas BA. Prevalence of cerebral vascular amyloid-beta deposition and stroke in an aging Australian population: a postmortem study. J Clin Neurosci 2003; 10:186-9. [PMID: 12637046 DOI: 10.1016/s0967-5868(02)00317-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is a putative risk factor for lobar cerebral haemorrhage and infarction in the elderly. However, the prevalence of stroke in a population with CAA is not known. Amyloid-beta immunohistochemistry was used to assess CAA prevalence as a function of age, and the relationship between CAA and stroke in 100 individuals aged 50-91 years who died unexpectedly and had a Coroner's postmortem. Blocks were taken from several cortical areas and from areas of infarction or haemorrhage. Parenchymal Abeta was first found in the 6th decade, whereas vascular Abeta did not appear until the 7th decade. The prevalence of both vascular and parenchymal Abeta increased with age to a maximum in the 9th decade. The age at onset of vascular Abeta deposition was similar to that in an English study of CAA but a decade later than in Japanese studies. There was no association between the presence of vascular Abeta and cerebral haemorrhage or infarction. The findings indicate differences in the time-course of vascular and parenchymal Abeta deposition with age, as well as racial differences. The lack of association between vascular Abeta and cerebral haemorrhage or infarction indicates that, in the present population, CAA was usually asymptomatic.
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Affiliation(s)
- F L Mastaglia
- Centre for Neuromuscular and Neurological Disorders, Australian Neuromuscular Research Institute, University of Western Australia, QEII Medical Centre, Nedlands, WA 6009, Australia.
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Oide T, Tokuda T, Takei YI, Takahashi H, Ito K, Ikeda SI. Serial CT and MRI findings in a patient with isolated angiitis of the central nervous system associated with cerebral amyloid angiopathy. Amyloid 2002; 9:256-62. [PMID: 12557755 DOI: 10.3109/13506120209114103] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report serial CT and MRI findings in a biopsy-proven case of cerebral amyloid angiopathy (CAA) with isolated angiitis of the central nervous system (CNS). A 69-year-old man had developed dizziness, dementia, and generalized seizure during the preceding 4 years. An initial examination by brain CT and MRI showed bilateral symmetrical periventricular lesions closely resembling those of Binswanger's disease. Subsequently, the lesions expanded slowly, involving a large area of the right cerebral hemisphere with an obvious mass effect. Since a primary brain tumor was suspected, a brain biopsy was performed, and histopathological examination revealed amyloid beta protein CAA within the meningocortical vessels associated with perivascular monocytic cuffing, indicating the presence of isolated angiitis of the CNS. Multinucleated giant cells containing intracytoplasmic beta protein amyloid around a heavily amyloid-laden cortical vessel were also observed. This is the first case report to show sequential radiographical studies of the leukoencephalopathy associated with CAA and isolated angiitis of the CNS.
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Affiliation(s)
- Takashi Oide
- Third Department of Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan
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Takashashi RH, Sawa H, Kuroda S, Saito H, Fujita M, Fujioka Y, Fukatsu R, Nagashima K. Pathologic processes leading to cerebral hemorrhage in amyloid angiopathy. Neuropathology 1996. [DOI: 10.1111/j.1440-1789.1996.tb00163.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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