Sporadic cerebral amyloid angiopathy--an important cause of cerebral haemorrhage in older people

Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia

BACKGROUND

Decreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)-guided stereotactic localization of hematomas in elderly patients diagnosed with ICH.

METHODS

The study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups.

RESULTS

No significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05).

CONCLUSIONS

A combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.

Preliminary exploration of the co-regulation of Alzheimer's disease pathogenic genes by microRNAs and transcription factors

Background

Alzheimer's disease (AD) is the most common form of age-related neurodegenerative disease. Unfortunately, due to the complexity of pathological types and clinical heterogeneity of AD, there is a lack of satisfactory treatment for AD. Previous studies have shown that microRNAs and transcription factors can modulate genes associated with AD, but the underlying pathophysiology remains unclear.

Methods

The datasets GSE1297 and GSE5281 were downloaded from the gene expression omnibus (GEO) database and analyzed to obtain the differentially expressed genes (DEGs) through the "R" language "limma" package. The GSE1297 dataset was analyzed by weighted correlation network analysis (WGCNA), and the key gene modules were selected. Next, gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment analysis for the key gene modules were performed. Then, the protein-protein interaction (PPI) network was constructed and the hub genes were identified using the STRING database and Cytoscape software. Finally, for the GSE150693 dataset, the "R" package "survivation" was used to integrate the data of survival time, AD transformation status and 35 characteristics, and the key microRNAs (miRNAs) were selected by Cox method. We also performed regression analysis using least absolute shrinkage and selection operator (Lasso)-Cox to construct and validate prognostic features associated with the four key genes using different databases. We also tried to find drugs targeting key genes through DrugBank database.

Results

GO and KEGG enrichment analysis showed that DEGs were mainly enriched in pathways regulating chemical synaptic transmission, glutamatergic synapses and Huntington's disease. In addition, 10 hub genes were selected from the PPI network by using the algorithm Between Centrality. Then, four core genes (TBP, CDK7, GRM5, and GRIA1) were selected by correlation with clinical information, and the established model had very good prognosis in different databases. Finally, hsa-miR-425-5p and hsa-miR-186-5p were determined by COX regression, AD transformation status and aberrant miRNAs.

Conclusion

In conclusion, we tried to construct a network in which miRNAs and transcription factors jointly regulate pathogenic genes, and described the process that abnormal miRNAs and abnormal transcription factors TBP and CDK7 jointly regulate the transcription of AD central genes GRM5 and GRIA1. The insights gained from this study offer the potential AD biomarkers, which may be of assistance to the diagnose and therapy of AD.

The Brilliance of the Zebrafish Model: Perception on Behavior and Alzheimer’s Disease

Alzheimer’s disease (AD) has become increasingly prevalent in the elderly population across the world. It’s pathophysiological markers such as overproduction along with the accumulation of amyloid beta (Aβ) plaques and neurofibrillary tangles (NFT) are posing a serious challenge to novel drug development processes. A model which simulates the human neurodegenerative mechanism will be beneficial for rapid screening of potential drug candidates. Due to the comparable neurological network with humans, zebrafish has emerged as a promising AD model. This model has been thoroughly validated through research in aspects of neuronal pathways analogous to the human brain. The cholinergic, glutamatergic, and GABAergic pathways, which play a role in the manifested behavior of the zebrafish, are well defined. There are several behavioral models in both adult zebrafish and larvae to establish various aspects of cognitive impairment including spatial memory, associative memory, anxiety, and other such features that are manifested in AD. The zebrafish model eliminates the shortcomings of previously recognized mammalian models, in terms of expense, extensive assessment durations, and the complexity of imaging the brain to test the efficacy of therapeutic interventions. This review highlights the various models that analyze the changes in the normal behavioral patterns of the zebrafish when exposed to AD inducing agents. The mechanistic pathway adopted by drugs and novel therapeutic strategies can be explored via these behavioral models and their efficacy to slow the progression of AD can be evaluated.

Plasma Amyloid Beta, Total-Tau and Neurofilament Light Chain Levels and the Risk of Stroke: A Prospective Population-Based Study

BACKGROUND AND OBJECTIVES

To unravel whether Alzheimer's disease-related pathology or neurodegeneration play a role in stroke etiology, we determined the effect of plasma levels amyloid β (Aβ), total-tau and neurofilament light chain (NfL) on risk of stroke and its subtypes.

METHODS

Between 2002 and 2005, we measured plasma Aβ40, Aβ42, total-tau, and NfL in 4,661 stroke-free participants from the population-based Rotterdam Study. We used Cox proportional-hazards models to determine the association between these markers with incident stroke for the entire cohort, per stroke subtype, and by median age, sex, Apolipoprotein E (APOE) ε4 carriership, and education.

RESULTS

After a mean follow-up of 10.8 ± 3.3 years, 379 participants suffered a first-ever stroke. Log2 total-tau at baseline showed a non-linear association with risk of any stroke and ischemic stroke: compared to the first (lowest) quartile the adjusted hazard ratio for the highest quartile total-tau was 1.68, 95% CI: 1.18-2.40 for any stroke. Log2 NfL was associated with an increased risk of any stroke (HR per SD increase 1.27, 95% CI: 1.12-1.44), ischemic stroke, and hemorrhagic stroke (HR 1.56, 95% CI: 1.14-2.12). Log2 Aβ40, Aβ42, and Aβ42/40 ratio levels were not associated with stroke risk.Discussion Participants with higher total-tau and NfL at baseline had a higher risk of stroke and several stroke subtypes. These findings support the role of markers of neurodegeneration in the etiology of stroke.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that higher plasma levels of total-tau and NfL are associated with an increased risk of subsequent stroke.

Copper accumulation and the effect of chelation treatment on cerebral amyloid angiopathy compared to parenchymal amyloid plaques

Accumulation of fibrillar amyloid β-protein (Aβ) in parenchymal plaques and in blood vessels of the brain, the latter condition known as cerebral amyloid angiopathy (CAA), are hallmark pathologies of Alzheimer's disease (AD) and related disorders. Cerebral amyloid deposits have been reported to accumulate various metals, most notably copper and zinc. Here we show that, in human AD, copper is preferentially accumulated in amyloid-containing brain blood vessels compared to parenchymal amyloid plaques. In light of this observation, we evaluated the effects of reducing copper levels in Tg2576 mice, a transgenic model of AD amyloid pathologies. The copper chelator, tetrathiomolybdate (TTM), was administered to twelve month old Tg2576 mice for a period of five months. Copper chelation treatment significantly reduced both CAA and parenchymal plaque load in Tg2576 mice. Further, copper chelation reduced parenchymal plaque copper content but had no effect on CAA copper levels in this model. These findings indicate that copper is associated with both CAA deposits and parenchymal amyloid plaques in humans, but less in Tg2576 mice. TTM only reduces copper levels in plaques in Tg2576 mice. Reducing copper levels in the brain may beneficially lower amyloid pathologies associated with AD.

Fatal pulmonary hemorrhage associated with vascular amyloid deposition in a cat

Case summary

An adult female spayed Siamese-cross cat of unknown age was presented for bilateral hemorrhagic otorrhea. Nasopharyngeal polyps were diagnosed by CT and biopsy; bilateral ventral bulla osteotomies were performed. Episodic epistaxis, otic hemorrhage and hemoptysis with respiratory distress progressed over 18 months. Systolic blood pressure, complete blood count, plasma biochemistries, prothrombin time, partial thromboplastin time and coagulation factor 12, 9 and 8 activities were normal. Serial thoracic radiographs revealed patchy interstitial to alveolar patterns. Airway hemorrhage prevented diagnostic bronchoscopy. Respiratory hemorrhage was ultimately fatal. Amyloid deposition was identified in pulmonary vasculature, bronchial wall, lymphoid tissues, nasal-pharyngeal tissue and tympanic bullae based on microscopic examination and confirmed by Congo red staining with green birefringence under polarized light.

Relevance and novel information

Amyloidosis should be considered as a differential diagnosis in cats with spontaneous hemorrhage of the respiratory or otic tracts. Although systemic amyloidosis is associated with a grave prognosis, this case suggests that prolonged survival is possible after the initial onset of signs in cats with pulmonary amyloidosis.

Metabolic Abnormalities of Erythrocytes as a Risk Factor for Alzheimer's Disease

Alzheimer's disease (AD) is a slowly progressive, neurodegenerative disorder of uncertain etiology. According to the amyloid cascade hypothesis, accumulation of non-soluble amyloid β peptides (Aβ) in the Central Nervous System (CNS) is the primary cause initiating a pathogenic cascade leading to the complex multilayered pathology and clinical manifestation of the disease. It is, therefore, not surprising that the search for mechanisms underlying cognitive changes observed in AD has focused exclusively on the brain and Aβ-inducing synaptic and dendritic loss, oxidative stress, and neuronal death. However, since Aβ depositions were found in normal non-demented elderly people and in many other pathological conditions, the amyloid cascade hypothesis was modified to claim that intraneuronal accumulation of soluble Aβ oligomers, rather than monomer or insoluble amyloid fibrils, is the first step of a fatal cascade in AD. Since a characteristic reduction of cerebral perfusion and energy metabolism occurs in patients with AD it is suggested that capillary distortions commonly found in AD brain elicit hemodynamic changes that alter the delivery and transport of essential nutrients, particularly glucose and oxygen to neuronal and glial cells. Another important factor in tissue oxygenation is the ability of erythrocytes (red blood cells, RBC) to transport and deliver oxygen to tissues, which are first of all dependent on the RBC antioxidant and energy metabolism, which finally regulates the oxygen affinity of hemoglobin. In the present review, we consider the possibility that metabolic and antioxidant defense alterations in the circulating erythrocyte population can influence oxygen delivery to the brain, and that these changes might be a primary mechanism triggering the glucose metabolism disturbance resulting in neurobiological changes observed in the AD brain, possibly related to impaired cognitive function. We also discuss the possibility of using erythrocyte biochemical aberrations as potential tools that will help identify a risk factor for AD.

Can brain impermeable BACE1 inhibitors serve as anti-CAA medicine?

Background

Cerebral amyloid angiopathy (CAA) is characterized by the deposition of ß-amyloid peptides (Aß) in and surrounding the wall of microvasculature in the central nervous system, together with parenchymal amyloid plaques collectively referred to as cerebral amyloidosis, which occurs in the brain commonly among the elderly and more frequently in patients with Alzheimer’s disease (AD). CAA is associated with vascular injury and may cause devastating neurological outcomes. No therapeutic approach is available for this lesion to date.

Main body

ß-Secretase 1 (BACE1) is the enzyme initiating Aß production. Brain permeable BACE1 inhibitors targeting primarily at the parenchymal plaque pathology are currently evaluated in clinical trials. This article presents findings in support of a role of BACE1 elevation in the development of CAA, in addition to plaque pathogenesis. The rationale, feasibility, benefit and strategic issues for developing BACE1 inhibitors against CAA are discussed. Brain impermeable compounds are considered preferable as they might exhibit sufficient anti-CAA efficacy without causing significant neuronal/synaptic side effects.

Conclusion

Early pharmacological intervention to the pathogenesis of CAA is expected to provide significant protection for cerebral vascular health and hence brain health. Brain impermeable BACE1 inhibitors should be optimized and tested as potential anti-CAA therapeutics.

Cerebral vascular amyloid seeds drive amyloid β-protein fibril assembly with a distinct anti-parallel structure

Cerebrovascular accumulation of amyloid β-protein (Aβ), a condition known as cerebral amyloid angiopathy (CAA), is a common pathological feature of patients with Alzheimer's disease. Familial Aβ mutations, such as Dutch-E22Q and Iowa-D23N, can cause severe cerebrovascular accumulation of amyloid that serves as a potent driver of vascular cognitive impairment and dementia. The distinctive features of vascular amyloid that underlie its unique pathological properties remain unknown. Here, we use transgenic mouse models producing CAA mutants (Tg-SwDI) or overproducing human wild-type Aβ (Tg2576) to demonstrate that CAA-mutant vascular amyloid influences wild-type Aβ deposition in brain. We also show isolated microvascular amyloid seeds from Tg-SwDI mice drive assembly of human wild-type Aβ into distinct anti-parallel β-sheet fibrils. These findings indicate that cerebrovascular amyloid can serve as an effective scaffold to promote rapid assembly and strong deposition of Aβ into a unique structure that likely contributes to its distinctive pathology.

Histological and immunohistochemical characteristics of cerebral amyloid angiopathy in elderly dogs

BACKGROUND

Cerebral amyloid angiopathy (CAA) is a disorder characterized by amyloid deposition in the wall of cerebral blood vessels. The deposits of amyloid occur frequently in the blood vessels of the frontal, parietal and occipital cortex.

OBJECTIVE

To examine the characteristics of CAA classified according to the Vonsattel scale in elderly dogs histologically and immunohistochemically as well as the semi-quantitative evaluation of the amyloid deposits in the different segments of the brain.

ANIMALS AND METHODS

The brains of 36 dogs of different breeds and sexes, which had been routinely necropsied, were used and divided into two groups: dogs from 1 to 5 and 10 to 18 years old. The tissue sections were stained by hematoxylin-eosin, Congo red and immunohistochemically.

RESULTS

Amyloid was accumulated in the wall of cerebral blood vessels in 70% of dogs over the age of 10 years predominantly in the frontal cortex. CAA was demonstrated in elderly dogs as follows: in the frontal cortex (n = 19 or 63%), the parietal cortex (n = 12 or 40%), the hippocampus (40%) and the cerebellum (n = 5 or 17%). The deposits of amyloid in the wall of blood vessels detected by Congo red staining were also Aβ1-14 and Aβ1-42 immunohistochemically positive. Most commonly, the amyloid deposits affected a moderate number of blood vessels. The accumulation of amyloid was immunohistochemically revealed in the blood vessel walls as well as in the senile plaques and neurons.

CONCLUSION

The amount of amyloid in the arterial walls increased with age in dogs, whereas the amyloid accumulated in plaques was Congo red negative.

The influence of the amyloid ß-protein and its precursor in modulating cerebral hemostasis

Ischemic and hemorrhagic strokes are a significant cause of brain injury leading to vascular cognitive impairment and dementia (VCID). These deleterious events largely result from disruption of cerebral hemostasis, a well-controlled and delicate balance between thrombotic and fibrinolytic pathways in cerebral blood vessels and surrounding brain tissue. Ischemia and hemorrhage are both commonly associated with cerebrovascular deposition of amyloid ß-protein (Aß). In this regard, Aß directly and indirectly modulates cerebral thrombosis and fibrinolysis. Further, major isoforms of the Aß precursor protein (AßPP) function as a potent inhibitor of pro-thrombotic proteinases. The purpose of this review article is to summarize recent research on how cerebral vascular Aß and AßPP influence cerebral hemostasis. This article is part of a Special Issue entitled: Vascular Contributions to Cognitive Impairment and Dementia, edited by M. Paul Murphy, Roderick A. Corriveau and Donna M. Wilcock.

Older age is a strong predictor for poor outcome in intracerebral haemorrhage: the INTERACT2 study

BACKGROUND AND PURPOSE

Global ageing contributes greatly to the burden of stroke. We investigated the influence of age on the baseline profile and on outcomes in acute intracerebral haemorrhage (ICH) among participants of the INTERACT2 study.

METHODS

INTERACT2 was an international, randomised controlled trial in 2839 patients with spontaneous ICH within 6 h of onset and elevated systolic blood pressure (SBP; 150-220 mmHg) who were allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) blood pressure lowering treatment. Stroke severity was assessed with the National Institutes of Health Stroke Scale. Poor outcome was defined as death or major disability ('dependency', modified Rankin Scale scores 3-6) at 90 days. Health-related quality of life (HRQoL) was assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Associations between age and outcomes were analysed in multivariable logistic regression models.

RESULTS

Stroke severity increased in categories of older age (P-trend 0.002). Stroke patients over 75 years old were four times more likely to die or be disabled at 90 days than those <52 years when other confounders were accounted for (odds ratio 4.36, 95% confidence interval 3.12-6.08). Older age was also associated with decreasing HRQoL, across mobility, self-care, usual activities and depression (all P-trend <0.001), and pain or discomfort (P-trend 0.022).

CONCLUSION

In the INTERACT2 cohort, older people had more severe ICH and worse outcomes (death, major disability and HRQoL). These data will help guide clinicians manage older people with haemorrhagic stroke.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov (NCT00716079).

Antithrombotic treatment and intracerebral haemorrhage: between Scylla and Charybdis

In patients who have intracerebral haemorrhage while on antithrombotic treatment, there is no evidence from randomised clinical trials to support decisions with regard to antithrombotic medication. In the acute phase, we advise stopping all antithrombotic treatment with rapid reversal of antithrombotic effects of oral anticoagulants. After the acute phase, we discourage restarting oral anticoagulants in patients with a lobar haematoma caused by cerebral amyloid angiopathy because of the high risk of recurrent bleeding. In these patients, even treatment with platelet inhibitors needs careful weighing of the risks of bleeding and ischaemic stroke. In patients with non-lobar intracerebral haemorrhage, we suggest considering restarting optimal antithrombotic treatment. This includes treatment with oral anticoagulants for patients with atrial fibrillation and/or mechanical valve prosthesis. After intracerebral haemorrhage during oral anticoagulant therapy in patients with atrial fibrillation, direct anticoagulants may be better than vitamin K antagonists, but we await confirmation of this from ongoing trials.

Recurrent cerebral amyloid angiopathy-related hemorrhage

Cerebral amyloid angiopathy is an important cause of intracerebral hemorrhage in normotensive elder individuals. Surgical treatment for cerebral hematoma due to amyloid angiopathy remains controversial, and some authors emphasized the difficulty of hemostasis during surgery and the risk of recurrent hemorrhage after surgery. A case study of a 68-year-old man with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Declining rates of fatal and nonfatal intracerebral hemorrhage: epidemiological trends in Australia

Background

A recent systematic review of epidemiological studies reported intracerebral hemorrhage (ICH) incidence and mortality as unchanged over time; however, comparisons between studies conducted in different health services obscure assessment of trends. We explored trends in ICH rates in a large, representative population in New South Wales, Australia's most populous state (≈7.3 million).

Methods and Results

Adult hospitalizations with a principal ICH diagnosis from 2001 to 2009 were linked to death registrations through to June 30, 2010. Trends for overall, fatal, and nonfatal ICH rates within 30 days and fatal rates for 30‐day survivors at 365 days were calculated. There were 11 332 ICH patient admissions meeting eligibility criteria, yielding a crude hospitalization rate of 25.2 per 100 000 (age‐standardized rate: 17.2). Age‐ and sex‐adjusted overall rates significantly declined by an average of 1.6% per year (P=0.03). Fatal ICH declined by an average of 2.6% per year (P=0.004). For 30‐day survivors, a nonsignificant decline of 2.3% per year in fatal ICH at 365 days was estimated (P=0.17). Male sex and birth in the Oceania region and Asia were associated with an increased ICH risk, although this depended on age. Approximately 12% of ICH admissions would be prevented if the socioeconomic circumstances of the population equated with those of the least disadvantaged.

Conclusions

Overall and fatal ICH rates have fallen in this large Australian population. Improvements in cardiovascular prevention and acute care may explain declining rates. There was no evidence of an increase in devastated survivors because the longer term mortality of 30‐day survivors has not increased over time.

Neuroinflammation after intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a particularly severe type of stroke for which no specific treatment has been established yet. Although preclinical models of ICH have substantial methodological limitations, important insight into the pathophysiology has been gained. Mounting evidence suggests an important contribution of inflammatory mechanisms to brain damage and potential repair. Neuroinflammation evoked by intracerebral blood involves the activation of resident microglia, the infiltration of systemic immune cells and the production of cytokines, chemokines, extracellular proteases and reactive oxygen species (ROS). Previous studies focused on innate immunity including microglia, monocytes and granulocytes. More recently, the role of adaptive immune cells has received increasing attention. Little is currently known about the interactions among different immune cell populations in the setting of ICH. Nevertheless, immunomodulatory strategies are already being explored in ICH. To improve the chances of translation from preclinical models to patients, a better characterization of the neuroinflammation in patients is desirable.

Primary Multiple Simultaneous Intracerebral Hemorrhages between 1950 and 2013: Analysis of Data on Age, Sex and Outcome

Background

Primary multiple simultaneous intracerebral hemorrhages (MSICHs) are quite rare. Although occasional reports have been found, there have been no systematic reviews. The published case reports and case series contain overlapping data, leading to erroneous information about MSICHs. This is the first extensive review of accessible studies published in English on MSICHs. Our primary objective was to analyze the demographic data on age, sex, outcome and prognosis with regard to primary MSICHs.

Summary

A PubMed search without language restriction for articles with results from human studies and registered between January 1950 and September 2013 yielded 677 articles. The following inclusion criteria were applied: (1) reported case(s) or case series on primary MSICHs; (2) text partly or fully in English, and (3) text contains identifiable data on age, sex and outcome of patients. A total of 24 articles met all the inclusion criteria. The reference lists of these 24 articles were inspected for additional relevant articles, which yielded another 20 articles. In all, 248 cases were identified; 143 cases were excluded for various reasons: 52 duplicate cases, 18 cases of multiple nonsimultaneous intracerebral hemorrhages, 25 cases of secondary MSICHs, and 48 cases with incomplete data on age, sex and outcome. The remaining 105 cases were analyzed. MSICHs were found to be more common in bilateral cases (53.33%): there were bilateral basal ganglia hemorrhages (33.33%), bilateral thalamic hemorrhages (18.10%), bilateral lobar hemorrhages (0.95%) and bilateral cerebellar hemorrhages (0.95%). Nonbilateral MSICHs were found in 46.67% of the cases. The hematomas were commonly distributed in the basal ganglia (45.83%), thalamus (30.56%) and cerebellum (10.19%). MSICHs were more frequently encountered in males (60.95%; average age: 59.13 ± 12.49 years). The average age of the female patients was higher (63.89 ± 13.11 years). Patients with primary MSICHs had a survival rate of 56.20%. There was a favorable outcome of primary MSICHs in 18.10% of all the cases, the highest proportion of which was in the nonbilateral MSICH group. The remaining 38.10% had unfavorable outcomes. Death occurred in 43.80% of all cases, the highest proportion being found in the bilateral basal ganglia hemorrhage group. Primary MSICHs share features with solitary intracerebral hemorrhage regarding age, sex, and the location and distribution of hematomas, but they have a poorer outcome (p < 0.05).

Key Messages

Primary MSICHs are rare and share features with solitary intracerebral hemorrhage regarding age and the location and distribution of hematomas. Patients have a poorer prognosis but higher favorable outcome rates in case of survival. This information adds to the awareness of clinicians that higher rates of favorable outcomes can be achieved for MSICHs.

Engineering theranostic nanovehicles capable of targeting cerebrovascular amyloid deposits

Cerebral amyloid angiopathy (CAA) is characterized by the deposition of amyloid beta (Aβ) proteins within the walls of the cerebral vasculature with subsequent aggressive vascular inflammation leading to recurrent hemorrhagic strokes. The objective of the study was to develop theranostic nanovehicles (TNVs) capable of a) targeting cerebrovascular amyloid; b) providing magnetic resonance imaging (MRI) contrast for the early detection of CAA; and c) treating cerebrovascular inflammation resulting from CAA. The TNVs comprised of a polymeric nanocore made from Magnevist (MRI contrast agent) conjugated chitosan. The nanocore was also loaded with cyclophosphamide (CYC), an immunosuppressant shown to reduce the cerebrovascular inflammation in CAA. Putrescine modified F(ab')2 fragment of anti-amyloid antibody, IgG4.1 (pF(ab')24.1) was conjugated to the surface of the nanocore to target cerebrovascular amyloid. The average size of the control chitosan nanoparticles (conjugated with albumin and are devoid of Magnevist, CYC, and pF(ab')24.1) was 164±1.2 nm and that of the TNVs was 239±4.1 nm. The zeta potential values of the CCNs and TNVs were 21.6±1.7 mV and 11.9±0.5 mV, respectively. The leakage of Magnevist from the TNVs was a modest 0.2% over 4 days, and the CYC release from the TNVs followed Higuchi's model that describes sustained drug release from polymeric matrices. The studies conducted in polarized human microvascular endothelial cell monolayers (hCMEC/D3) in vitro as well as in mice in vivo have demonstrated the ability of TNVs to target cerebrovascular amyloid. In addition, the TNVs provided contrast for imaging cerebrovascular amyloid using MRI and single photon emission computed tomography. Moreover, the TNVs were shown to reduce pro-inflammatory cytokine production by the Aβ challenged blood brain barrier (BBB) endothelium more effectively than the cyclophosphamide alone.

A unique case report of cerebral amyloid angiopathy with literature review

Cerebral amyloid angiopathy (CAA) is a cerebrovascular disease in which β-amyloid peptides are deposited in leptomeningeal, cortical, and subcortical arteries, arterioles, and capillaries. Most individuals with CAA are asymptomatic. However, patients with CAA can present with cognitive impairment and other neurologic deficits caused by vascular wall amyloid deposition leading to hemorrhage. We present a unique case of CAA in a middle-aged woman with a history of cerebral cortex microhemorrhages and cortical edema. Imaging and pathology findings suggested CAA as the main etiology of this presentation. This is a very rare case of CAA coexisting with aneurysmal subarachnoid hemorrhage. Finally, we present a full discussion on the pathogenesis, clinical features, diagnosis, and treatment of CAA.

Cerebral Amyloidal Angiopathy--a disease with implications for neurology and psychiatry

Cerebral Amyloidal Angiopathy (CAA), which occurs sporadically in most cases but can also occur hereditarily, belongs to the group amyloidoses and is characterized by the deposition and accumulation of beta-amyloid (Aβ) in smaller arterial vessels of the brain. The deposition of Aβ leads to degenerative changes in the cerebral vessel system (thickening of the vessel wall, microaneurysm, constriction of vascular lumen, dissection), which favour the development of the clinical symptomatology most often associated with CAA. Besides haemorrhages, cerebral ischaemia, transient neurological symptoms, leukoencephalopathy as well as cognitive decline and even dementia may appear in connection with CAA. A definite diagnosis of CAA can only be made on the basis of a pathological assessment, even though diagnostic findings of cerebral neuroimaging and clinical symptoms allow the diagnosis of a probable CAA. At present, no causal therapy options are available. Although CAA is placed within the range of neurological illnesses, psychiatric symptoms such as cognitive impairment, personality change or behavioural problems as well as depression are plausible clinical manifestations of CAA and may even dominate the clinical picture. Apart from epidemiological, pathogenetical, clinical and diagnostical aspects, possible psychiatric implications of CAA are discussed in the review article.

SC1/hevin identifies early white matter injury after ischemia and intracerebral hemorrhage in young and aged rats

The progression of white matter damage after ischemic and hemorrhagic strokes can exacerbate the initial injury, but little is known about the processes involved. We show that the antiadhesive matricellular glycoprotein SC1 is a novel early marker of white matter damage in 3 models of acute injury in the rat striatum: transient focal ischemia, intracerebral hemorrhage, and a needle penetration wound. SC1 was restricted to the damaged portions of axon bundles that bordered stroke lesions in young-adult and aged rats. SC1 peaked at 1 and 3 days after intracerebral hemorrhage and at 7 days after ischemia. The SC1-positive bundles usually expressed degraded myelin basic protein and amyloid precursor protein, a marker of axonal injury. At the hematoma edge, SC1 was seen in a few axon bundles that retained myelin basic protein staining. In these bundles, punctate SC1 staining filled individual axons, extended beyond a core of pan-axonal neurofilament and NF200 and was inside or overlapped with myelin basic protein staining when it was present. Aged rats had less SC1 (and amyloid precursor protein) after both types of stroke, suggesting a reduced axonal response. SC1 also labeled amyloid precursor protein-positive axon bundles along the needle penetration tract of saline-injected rats; thus, SC1 appears to characterize damaged striatal white matter damage after multiple types of injury.

Age-related comparisons of evolution of the inflammatory response after intracerebral hemorrhage in rats

In the hours to days after intracerebral hemorrhage (ICH), there is an inflammatory response within the brain characterized by the infiltration of peripheral neutrophils and macrophages and the activation of brain-resident microglia and astrocytes. Despite the strong correlation of aging and ICH incidence, and increasing information about cellular responses, little is known about the temporal- and age-related molecular responses of the brain after ICH. Here, we monitored a panel of 27 genes at 6 h and 1, 3, and 7 days after ICH was induced by injecting collagenase into the striatum of young adult and aged rats. Several molecules (CR3, TLR2, TLR4, IL-1β, TNFα, iNOS, IL-6) were selected to reflect the classical activation of innate immune cells (macrophages, microglia) and the potential to exacerbate inflammation and damage brain cells. Most of the others are associated with the resolution of innate inflammation, alternative pathways of macrophage/microglial activation, and the repair phase after acute injury (TGFβ, IL-1ra, IL-1r2, IL-4, IL-13, IL-4Rα, IL-13Rα1, IL-13Rα2, MRC1, ARG1, CD163, CCL22). In young animals, the up-regulation of 26 in 27 genes (not IL-4) was detected within the first week. Differences in timing or levels between young and aged animals were detected for 18 of 27 genes examined (TLR2, GFAP, IL-1β, IL-1ra, IL-1r2, iNOS, IL-6, TGFβ, MMP9, MMP12, IL-13, IL-4Rα, IL-13Rα1, IL-13Rα2, MRC1, ARG1, CD163, CCL22), with a generally less pronounced or delayed inflammatory response in the aged animals. Importantly, within this complex response to experimental ICH, the induction of pro-inflammatory, potentially harmful mediators often coincided with resolving and beneficial molecules.

Spontaneous upper limb monoplegia secondary to probable cerebral amyloid angiopathy

Cerebral amyloid angiopathy is a clinicopathological disorder characterised by vascular amyloid deposition initially in leptomeningeal and neocortical vessels, and later affecting cortical and subcortical regions. The presence of amyloid within the walls of these vessels leads to a propensity for primary intracerebral haemorrhage. We report the unusual case of a 77-year-old female who presented to our emergency department with sudden onset isolated hypoaesthesia and right upper limb monoplegia. A CT scan demonstrated a peripheral acute haematoma involving the left perirolandic cortices. Subsequent magnetic resonance imaging demonstrated previous superficial haemorrhagic events. One week following discharge the patient re-attended with multiple short-lived episodes of aphasia and jerking of the right upper limb. Further imaging demonstrated oedematous changes around the previous haemorrhagic insult. Cerebral amyloid angiopathy is an overlooked cause of intracerebral haemorrhage; the isolated nature of the neurological deficit in this case illustrates the many guises in which it can present.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Unexpectedly low prevalence of intracerebral hemorrhages in sporadic cerebral amyloid angiopathy: an autopsy study

In a retrospective study of a consecutive autopsy series of 2060 elderly subjects (mean age 78.5 +/- 6.8 SD years), sporadic cerebral amyloid angiopathy (CAA) of various degrees was detected in 73.2% and in 98.5% of autopsy-confirmed cases of typical (plaque and tangle) Alzheimer disease (AD). Spontaneous (non-traumatic) intracerebral hemorrhages (ICH) (excluding microbleeds) were seen in 5.6% of the total cohort and in 7.2% of definite AD cases; CAA was found in 49% of brains without and in 48.7% with ICH which was not significantly different. The latter groups showed a significantly higher frequency of severe degrees of CAA than those without ICH (80.4 vs 30.9%, p < 0.001). Patients with CAA were older than those without CAA, showing a higher frequency of clinical dementia and pathologically confirmed AD, but signs of hypertension (history and/or autopsy) were seen in 41 and 33.6% of these cases, respectively, compared to 70-75% in patients with non-CAA related ICHs. CAA-related ICH much more frequently involved cerebral lobes or hemispheres, while non-CAA related lesions were more often located in basal ganglia and brainstem. The data of a lower prevalence of CAA in cases without than with ICH, but a similar prevalence of ICH with and without CAA do not support the concept that CAA represents the most evident risk factor for ICH in the aged. While severe degrees of CAA were indeed associated with ICH, the general prevalence of large ICH in this autopsy cohort was much higher in cases without CAA, probably due to other risk factors including hypertension, which was documented in around 40% of cases with CAA-related ICH. APOE epsilon3/4 and epsilon4/4 were significantly more frequent in AD (n = 163) than in age-matched controls (n = 47) and were associated with more severe degrees of CAA, but no general genotyping in ICHs with and without CAA was performed. Hence, the role of APOE in the pathogenesis of ICH with and without CAA needs further elucidation.

Sporadic cerebral amyloid angiopathy is not a frequent cause of spontaneous brain hemorrhage

The retrospective study of a consecutive autopsy series of 1100 elderly subjects (mean age 78.3 +/- 6.8 SD years), revealed sporadic cerebral amyloid angiopathy (CAA) in 50.0% and in 95.7% of autopsy-confirmed cases of Alzheimer disease (AD). Apolipoprotein (APOE) epsilon 3/4 and epsilon 4/4 were significantly more frequent in AD than in controls, and were associated with more severe degrees of CAA. Spontaneous (non-traumatic) intracerebral hemorrhages (ICH) (excluding microbleeds and hemorrhagic infarctions) were seen in 5.4% and only in 3.3% of AD cases. CAA was found in 50.6% of brains without and in 42.4% with ICH, the latter showing a significantly higher frequency of severe degrees of CAA. ICH was related to CAA in 42.4%, whilst no such relation was seen in 57.6%. Patients with CAA were older, showed a higher frequency of clinical dementia and pathologically confirmed AD, but signs of hypertension (history and/or autopsy) occurred in 40%, compared with 80% in those with non-CAA-related ICHs. CAA-related ICH more frequently involved in cerebral lobes or hemispheres, whilst non-CAA-related ones were more often located in the basal ganglia and brainstem. The data of a lower prevalence of CAA in cases with than without ICH and of ICH with and without CAA do not support the concept that CAA represents the most important risk factor for ICH in the aged, probably because of other risk factors including hypertension.