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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 METHODS We present clinical and neuroradiological observations in seven unpublished CAA-RI cases, including neuropathological findings in two definite cases.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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Seifert RM, Rauch M, Klingebiel R, Boese LM, Greeve I, Rudwaleit M, Schäbitz WR. Case report: Cerebral amyloid angiopathy-related inflammation in a patient with granulomatosis with polyangiitis. Front Neurol 2023; 14:1277843. [PMID: 38020617 PMCID: PMC10666051 DOI: 10.3389/fneur.2023.1277843] [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] [Received: 08/15/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Cerebral amyloid angiopathy-related inflammation (CAA-ri) defines a subacute autoimmune encephalopathy, which is presumably caused by increased CSF concentrations of anti-Aβ autoantibodies. This autoinflammatory reaction is temporally and regionally associated with microglial activation, inflammation and radiological presence of vasogenic edema. Clinical characteristics include progressive demential development as well as headache and epileptic seizures. In the absence of histopathologic confirmation, the criteria defined by Auriel et al. allow diagnosis of probable resp. possible CAA-ri. CAA-ri shows responsiveness to immunosuppressive therapies and a possible coexistence with other autoinflammatory diseases. Methods We present a case report and literature review on the diagnosis of CAA-ri in a patient with known granulomatosis with polyangiitis (GPA). Results Initially, the presented patient showed neuropsychiatric abnormalities and latent arm paresis. Due to slight increase in CSF cell count, an initial antiviral therapy was started. MR tomography showed a pronounced frontotemporal edema as well as cerebral microhemorrhages, leading to the diagnosis of CAA-ri. Subsequent high-dose steroid treatment followed by six intravenous cyclophosphamide pulses resulted in decreased CSF cell count and regression of cerebral MRI findings. Conclusion The symptoms observed in the patient are consistent with previous case reports on CAA-ri. Due to previously known GPA, we considered a cerebral manifestation of this disease as a differential diagnosis. However, absence of pachymeningitis as well as granulomatous infiltrations on imaging made cerebral GPA less likely. An increased risk for Aβ-associated pathologies in systemic rheumatic diseases is discussed variously.
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Affiliation(s)
- Rebecca M. Seifert
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Michael Rauch
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Lennart-Maximilian Boese
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Isabell Greeve
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Martin Rudwaleit
- Universitätsklinik für Innere Medizin und Rheumatologie, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
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Bei J, Miranda-Morales EG, Gan Q, Qiu Y, Husseinzadeh S, Liew JY, Chang Q, Krishnan B, Gaitas A, Yuan S, Felicella M, Qiu WQ, Fang X, Gong B. Circulating exosomes from Alzheimer's disease suppress VE-cadherin expression and induce barrier dysfunction in recipient brain microvascular endothelial cell. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.03.535441. [PMID: 37066187 PMCID: PMC10103966 DOI: 10.1101/2023.04.03.535441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Background Blood-brain barrier (BBB) breakdown is a component of the progression and pathology of Alzheimer's disease (AD). BBB dysfunction is primarily caused by reduced or disorganized tight junction or adherens junction proteins of brain microvascular endothelial cell (BMEC). While there is growing evidence of tight junction disruption in BMECs in AD, the functional role of adherens junctions during BBB dysfunction in AD remains unknown. Exosomes secreted from senescent cells have unique characteristics and contribute to modulating the phenotype of recipient cells. However, it remains unknown if and how these exosomes cause BMEC dysfunction in AD. Objectives This study aimed to investigate the potential roles of AD circulating exosomes and their RNA cargos in brain endothelial dysfunction in AD. Methods We isolated exosomes from sera of five cases of AD compared with age- and sex-matched cognitively normal controls using size-exclusion chromatography technology. We validated the qualities and particle sizes of isolated exosomes with nanoparticle tracking analysis and atomic force microscopy. We measured the biomechanical natures of the endothelial barrier of BMECs, the lateral binding forces between live BMECs, using fluidic force miscopy. We visualized the paracellular expressions of the key adherens junction protein VE-cadherin in BMEC cultures and a 3D BBB model that employs primary human BMECs and pericytes with immunostaining and evaluated them using confocal microscopy. We also examined the VE-cadherin signal in brain tissues from five cases of AD and five age- and sex-matched cognitively normal controls. Results We found that circulating exosomes from AD patients suppress the paracellular expression levels of VE-cadherin and impair the barrier function of recipient BMECs. Immunostaining analysis showed that AD circulating exosomes damage VE-cadherin integrity in a 3D model of microvascular tubule formation. We found that circulating exosomes in AD weaken the BBB depending on the RNA cargos. In parallel, we observed that microvascular VE-cadherin expression is diminished in AD brains compared to normal controls. Conclusion Using in vitro and ex vivo models, our study illustrates that circulating exosomes from AD patients play a significant role in mediating the damage effect on adherens junction of recipient BMEC of the BBB in an exosomal RNA-dependent manner. This suggests a novel mechanism of peripheral senescent exosomes for AD risk.
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Bei J, Miranda-Morales EG, Gan Q, Qiu Y, Husseinzadeh S, Liew JY, Chang Q, Krishnan B, Gaitas A, Yuan S, Felicella M, Qiu WQ, Fang X, Gong B. Circulating Exosomes from Alzheimer's Disease Suppress Vascular Endothelial-Cadherin Expression and Induce Barrier Dysfunction in Recipient Brain Microvascular Endothelial Cell. J Alzheimers Dis 2023; 95:869-885. [PMID: 37661885 DOI: 10.3233/jad-230347] [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] [Indexed: 09/05/2023]
Abstract
BACKGROUND Blood-brain barrier (BBB) breakdown is a crucial aspect of Alzheimer's disease (AD) progression. Dysfunction in BBB is primarily caused by impaired tight junction and adherens junction proteins in brain microvascular endothelial cells (BMECs). The role of adherens junctions in AD-related BBB dysfunction remains unclear. Exosomes from senescent cells have unique characteristics and contribute to modulating the phenotype of recipient cells. However, it remains unknown if and how these exosomes cause BMEC dysfunction in AD. OBJECTIVE This study aimed to investigate the impact of AD circulating exosomes on brain endothelial dysfunction. METHODS Exosomes were isolated from sera of AD patients and age- and sex-matched cognitively normal controls using size-exclusion chromatography. The study measured the biomechanical nature of BMECs' endothelial barrier, the lateral binding forces between live BMECs. Paracellular expressions of the key adherens junction protein vascular endothelial (VE)-cadherin were visualized in BMEC cultures and a 3D BBB model using human BMECs and pericytes. VE-cadherin signals were also examined in brain tissues from AD patients and normal controls. RESULTS Circulating exosomes from AD patients reduced VE-cadherin expression levels and impaired barrier function in recipient BMECs. Immunostaining analysis demonstrated that AD exosomes damaged VE-cadherin integrity in a 3D microvascular tubule formation model. The study found that AD exosomes weakened BBB integrity depending on their RNA content. Additionally, diminished microvascular VE-cadherin expression was observed in AD brains compared to controls. CONCLUSION These findings highlight the significant role of circulating exosomes from AD patients in damaging adherens junctions of recipient BMECs, dependent on exosomal RNA.
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Affiliation(s)
- Jiani Bei
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ernesto G Miranda-Morales
- Department of Neurology, Mitchell Center for Neurodegenerative Diseases, University of Texas Medical Branch, Galveston, TX, USA
| | - Qini Gan
- Alzheimer's Disease Center, Boston University School of Medicine, Boston, MA, USA
| | - Yuan Qiu
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Sorosh Husseinzadeh
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jia Yi Liew
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Qing Chang
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Balaji Krishnan
- Department of Neurology, Mitchell Center for Neurodegenerative Diseases, University of Texas Medical Branch, Galveston, TX, USA
| | - Angelo Gaitas
- The Estelle and Daniel Maggin Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Subo Yuan
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Michelle Felicella
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Wei Qiao Qiu
- Alzheimer's Disease Center, Boston University School of Medicine, Boston, MA, USA
| | - Xiang Fang
- Department of Neurology, Mitchell Center for Neurodegenerative Diseases, University of Texas Medical Branch, Galveston, TX, USA
| | - Bin Gong
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
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Cerebral Amyloid Angiopathy-Related Inflammation: A Single-Center Experience and a Literature Review. J Clin Med 2022; 11:jcm11226731. [PMID: 36431207 PMCID: PMC9692654 DOI: 10.3390/jcm11226731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Limited data exist regarding the prevalence of clinical, neuroimaging, and genetic markers among patients diagnosed with Cerebral Amyloid Angiopathy−related inflammation (CAA-ri). We sought to determine these characteristics in patients diagnosed in our center and to summarize available literature published either as single-case reports or small case series (<5 patients). Methods: We reported our single-center experience of patients diagnosed with CAA-ri according to international criteria during a seven-year period (2015−2022), and we abstracted data from 90 previously published cases. Results: Seven patients (43% women, mean age 70 ± 13 years) were diagnosed with CAA-ri in our center. The most common symptom at presentation was focal neurological dysfunction (71%), and the most prevalent radiological finding was the presence of T2/FLAIR white matter hyperintensities (100%). All patients were treated with corticosteroids and had a favorable functional outcome. Among 90 previously published CAA-ri cases (51% women, mean age 70 ± 9 years), focal neurological dysfunction was the most common symptom (76%), followed by a cognitive decline (46%) and headache (34%). The most prevalent neuroimaging findings were cerebral microbleeds (85%), asymmetric T2/FLAIR white matter hyperintensities (81%), and gadolinium-enhancing T1-lesions (37%). Genetic testing for the Apolipoprotein-E gene was available in 27 cases; 59% carried the APOE ε4/ε4 genotype. The majority of the published CAA-ri cases (78%) received corticosteroid monotherapy, while 17 patients (19%) were treated with additional immunosuppressive treatment. Favorable functional outcome following treatment was documented in 70% of patients. Conclusion: Improving the vigilance of clinicians regarding the early recognition and accurate diagnosis of CAA-ri is crucial for swift therapy initiation, which may result in improved functional outcomes.
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