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Castellani RJ, Jamshidi P. Cerebral amyloid-β-related angiitis and iatrogenic cerebral amyloid angiopathy-related vasculitis: Implications for amyloid-related imaging abnormalities. J Neuropathol Exp Neurol 2024:nlae068. [PMID: 38970388 DOI: 10.1093/jnen/nlae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2024] Open
Affiliation(s)
- Rudy J Castellani
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Pouya Jamshidi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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2
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Urbach H, Linn J, Hattingen E, Fiebach J. Imaging of Amyloid-Related Imaging Abnormalities (ARIA). ROFO-FORTSCHR RONTG 2024; 196:363-369. [PMID: 37995736 DOI: 10.1055/a-2185-8472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Patients with Alzheimer's disease (AD) can now be treated with monoclonal antibodies aiming at clearing amyloid plaques from the brain parenchyma. Weeks after initiation of this drug therapy, patients may develop so-called amyloid-related imaging abnormalities (ARIA) on MRI. ARIA comprise vasogenic edema and leptomeningeal effusions (ARIA-E) as well as microbleeds and superficial hemosiderosis (ARIA-H). The prevalence is drug- and dose-dependent (up to 40 % of patients), the apolipoprotein E4 variant and concomitant cerebral amyloid angiopathy (CAA) increase the risk. With regard to MRI characteristics, ARIA strongly resembles the so-called inflammatory subtype of CAA (CAA-ri). While patients with CAA-ri are typically detected due to symptoms such as headaches, lethargy, confusion, and rarely epileptic seizures, around 20 % of ARIA patients show symptoms. Management of ARIA is not yet clearly established. In asymptomatic patients, discontinuation of the drug might be sufficient. KEY POINTS: · Amyloid-related imaging abnormalities (ARIA) occur in around 20 % of patients who are treated with monoclonal antibodies against amyloid β.. · There are 2 types: ARIA-E (edema effusion) und ARIA-H (hemorrhage).. · Depending on the severity, therapy with monoclonal antibodies is either interrupted or finished.. CITATION FORMAT: · Urbach H, Linn J, Hattingen E et al. Imaging of Amyloid-Related Imaging Abnormalities (ARIA). Fortschr Röntgenstr 2024; 196: 363 - 369.
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Affiliation(s)
- Horst Urbach
- Dept. of Neuroradiology, University Medical Center Freiburg, Germany
| | - Jennifer Linn
- Dept. of Neuroradiology, University Medical Center Dresden, Germany
| | - Elke Hattingen
- Dept. of Neuroradiology, University Medical Center Frankfurt, Germany
| | - Jochen Fiebach
- CSB-Neuroradiology, Charite University Hospital Berlin, Germany
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3
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Solopova E, Romero-Fernandez W, Harmsen H, Ventura-Antunes L, Wang E, Shostak A, Maldonado J, Donahue MJ, Schultz D, Coyne TM, Charidimou A, Schrag M. Fatal iatrogenic cerebral β-amyloid-related arteritis in a woman treated with lecanemab for Alzheimer's disease. Nat Commun 2023; 14:8220. [PMID: 38086820 PMCID: PMC10716177 DOI: 10.1038/s41467-023-43933-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
We report the case of a 79-year-old woman with Alzheimer's disease who participated in a Phase III randomized controlled trial called CLARITY-AD testing the experimental drug lecanemab. She was randomized to the placebo group and subsequently enrolled in an open-label extension which guaranteed she received the active drug. After the third biweekly infusion, she suffered a seizure characterized by speech arrest and a generalized convulsion. Magnetic resonance imaging revealed she had multifocal swelling and a marked increase in the number of cerebral microhemorrhages. She was treated with an antiepileptic regimen and high-dose intravenous corticosteroids but continued to worsen and died after 5 days. Post-mortem MRI confirmed extensive microhemorrhages in the temporal, parietal and occipital lobes. The autopsy confirmed the presence of two copies of APOE4, a gene associated with a higher risk of Alzheimer's disease, and neuropathological features of moderate severity Alzheimer's disease and severe cerebral amyloid angiopathy with perivascular lymphocytic infiltrates, reactive macrophages and fibrinoid degeneration of vessel walls. There were deposits of β-amyloid in meningeal vessels and penetrating arterioles with numerous microaneurysms. We conclude that the patient likely died as a result of severe cerebral amyloid-related inflammation.
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Affiliation(s)
- Elena Solopova
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Hannah Harmsen
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Emmeline Wang
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alena Shostak
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jose Maldonado
- Vanderbilt Neurovisualization Lab, Vanderbilt University, Nashville, TN, USA
| | - Manus J Donahue
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel Schultz
- Final Diagnosis: Private Autopsy Florida - Forensic Pathology Lab, Tampa, FL, USA
| | - Thomas M Coyne
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | | | - Matthew Schrag
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
- The Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA.
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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4
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Berry-Noronha A, Bonavia L, Smith T, Sahathevan R. Cerebral amyloid angiopathy related inflammation: An under recognized but treatable complication of cerebral amyloid angiopathy. Radiol Case Rep 2023; 18:2362-2365. [PMID: 37179808 PMCID: PMC10172615 DOI: 10.1016/j.radcr.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023] Open
Abstract
Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a subset of cerebral amyloid angiopathy (CAA) causing a reversible encephalopathy characterized by seizures and focal neurological deficit. Previously, biopsy was required to make this diagnosis, distinct radiological features have allowed development for clinicoradiological criteria to assist in diagnosis. CAA-ri is an important condition to recognize as patients respond to high dose corticosteroids with significant resolution of symptoms. A 79-year-old woman presents with new onset seizures and delirium with prior history of mild cognitive impairment. An initial computed tomography (CT) brain demonstrated vasogenic oedema in the right temporal lobe, and magnetic resonance imaging (MRI) showed bilateral subcortical white matter change and multiple microhemorrhages. The MRI findings were suggestive of cerebral amyloid angiopathy. Cerebrospinal fluid analysis demonstrated raised protein and oligoclonal bands. A thorough septic and autoimmune screen demonstrated no abnormality. Following a multidisciplinary discussion, a diagnosis of CAA-ri was made. She was commenced on dexamethasone and her delirium improved. CAA-ri is an important diagnostic consideration in an elderly patient who presents with new seizures. Clinicoradiological criteria are useful diagnostic tools and may avoid the need for invasive histopathological diagnosis.
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Affiliation(s)
| | - Luke Bonavia
- Grampians Health Ballarat, Ballarat, Victoria, Australia
| | - Tia Smith
- Grampians Health Ballarat, Ballarat, Victoria, Australia
| | - Ramesh Sahathevan
- Grampians Health Ballarat, Ballarat, Victoria, Australia
- Department of Medicine, University of Deakin, Geelong, Victoria, Australia
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5
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de Souza A, Tasker K. Inflammatory Cerebral Amyloid Angiopathy: A Broad Clinical Spectrum. J Clin Neurol 2023; 19:230-241. [PMID: 37151140 PMCID: PMC10169922 DOI: 10.3988/jcn.2022.0493] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a common central nervous system (CNS) vasculopathy, which in some cases is associated with subacute encephalopathy, seizures, headaches, or strokes due to vascular inflammation directed against vascular amyloid accumulation. The pathological subtypes of inflammatory CAA include CAA-related inflammation (CAAri) with mostly perivascular lymphocytic infiltrates, or amyloid-beta (Aβ)-related angiitis (ABRA) with transmural granulomatous inflammation. CAAri and ABRA probably represent part of the spectrum of CNS vasculopathies, intermediate between CAA and primary CNS vasculitis, and they are closely related to Aβ-related imaging abnormalities and other manifestations of an inflammatory response directed against Aβ in the leptomeninges and cerebral parenchyma. As treatment strategies in Alzheimer's disease shift toward potentially effective antiamyloid immunotherapy, the incidence rate of inflammatory CAA (which is probably an underrecognized condition) is likely to increase. Its clinical features are varied and include subacute encephalopathy, behavioral symptoms, headaches, seizures, and focal neurological deficits, which necessitate a high degree of suspicion for this disorder that often responds to treatment. The recent definition of the typical clinical and radiological syndrome has increased its recognition and may eliminate the need for invasive histological sampling in at least some affected patients. Here we review the pathophysiology, clinical spectrum, and approach to diagnosis, and discuss illustrative cases that highlight the wide range of clinical presentations.
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Affiliation(s)
- Aaron de Souza
- Department of Medicine, Launceston General Hospital, Launceston, Australia
- Faculty of Medicine, Launceston Clinical School, University of Tasmania, Launceston, Australia.
| | - Kate Tasker
- Department of Medicine, Launceston General Hospital, Launceston, Australia
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6
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Castellani RJ, Shanes E, McCord M, Reish NJ, Flanagan ME, Mesulam MM, Jamshidi P. Neuropathology of Anti-Amyloid-β Immunotherapy: A Case Report. J Alzheimers Dis 2023; 93:803-813. [PMID: 37125554 DOI: 10.3233/jad-221305] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Host responses to anti-amyloid-β (Aβ) antibody therapy are evident in neuroimaging changes and clinical symptoms in a subset of clinical trial subjects receiving such therapy. The pathological basis for the imaging changes and clinical symptoms is not known, nor is the precise mechanism of Aβ clearing. We report the autopsy findings in a 65-year-old woman who received three open label infusions of the experimental anti-Aβ drug lecanemab over about one month. Four days after the last infusion, she was treated with tissue plasminogen activator for acute stroke symptoms and died several days later with multifocal hemorrhage. Neuropathological examination demonstrated histiocytic vasculitis involving blood vessels with cerebral amyloid angiopathy. Fragmentation and phagocytosis of vascular Aβ were present throughout the cerebral cortex. Phagocytosis of parenchymal Aβ plaques was noted. Changes suggestive of Aβ and phosphorylated tau "clearing" were also noted. The findings overall suggest that anti-Aβ treatment stimulated a host response to Aβ, i.e., target engagement. The findings also provide evidence that amyloid-related imaging abnormalities might be indicative of an Aβ phagocytic syndrome within cerebral vasculature and parenchymal brain tissue in some cases.
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Affiliation(s)
- Rudolph J Castellani
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elisheva Shanes
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew McCord
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas J Reish
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Margaret E Flanagan
- Department of Pathology, University of Texas, San Antonio, San Antonio, TX, USA
| | - M-Marsel Mesulam
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pouya Jamshidi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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7
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Sakai K, Noguchi-Shinohara M, Tanaka H, Ikeda T, Hamaguchi T, Kakita A, Yamada M, Ono K. Cerebrospinal Fluid Biomarkers and Amyloid-β Elimination from the Brain in Cerebral Amyloid Angiopathy-Related Inflammation. J Alzheimers Dis 2023; 91:1173-1183. [PMID: 36565118 DOI: 10.3233/jad-220838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) biomarkers in patients with cerebral amyloid angiopathy-related inflammation (CAA-ri) have demonstrated inconsistent results. OBJECTIVE We investigated the relationship between CSF amyloid-β protein (Aβ) and vascular pathological findings to elucidate the mechanisms of Aβ elimination from the brain in CAA-ri. METHODS We examined Aβ40 and Aβ42 levels in CSF samples in 15 patients with CAA-ri and 15 patients with Alzheimer's disease and cerebral amyloid angiopathy (AD-CAA) using ELISA as a cross-sectional study. Furthermore, we pathologically examined Aβ40 and Aβ42 depositions on the leptomeningeal blood vessels (arteries, arterioles, and veins) using brain biopsy samples from six patients with acute CAA-ri and brain tissues of two autopsied patients with CAA-ri. RESULTS The median Aβ40 and Aβ42 levels in the CSF showed no significant difference between pre-treatment CAA-ri (Aβ40, 6837 pg/ml; Aβ42, 324 pg/ml) and AD-CAA (Aβ40, 7669 pg/ml, p = 0.345; Aβ42, 355 pg/ml, p = 0.760). Aβ40 and Aβ42 levels in patients with post-treatment CAA-ri (Aβ40, 1770 pg/ml, p = 0.056; Aβ42, 167 pg/ml, p = 0.006) were lower than those in patients with pre-treatment CAA-ri. Regarding Aβ40 and Aβ42 positive arteries, acute CAA-ri cases showed a higher frequency of partially Aβ-deposited blood vessels than postmortem CAA-ri cases (Aβ40, 20.8% versus 3.9%, p = 0.0714; Aβ42, 27.4% versus 2.0%, p = 0.0714, respectively). CONCLUSION Lower levels of CSF Aβ40 and Aβ42 could be biomarkers for the cessation of inflammation in CAA-ri reflecting the recovery of the intramural periarterial drainage pathway and vascular function.
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Affiliation(s)
- Kenji Sakai
- Department of Neurology, Joetsu General Hospital, Joetsu, Japan.,Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Moeko Noguchi-Shinohara
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan.,Department of Preemptive Medicine for Dementia, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hidetomo Tanaka
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Tokuhei Ikeda
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Tsuyoshi Hamaguchi
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan.,Department of Neurology, Kanazawa Medical University, Uchinada, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masahito Yamada
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan.,Department of Internal Medicine, Kudanzaka Hospital, Tokyo, Japan
| | - Kenjiro Ono
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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8
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Theodorou A, Palaiodimou L, Malhotra K, Zompola C, Katsanos AH, Shoamanesh A, Boviatsis E, Dardiotis E, Spilioti M, Sacco S, Werring DJ, Cordonnier C, Alexandrov AV, Paraskevas GP, Tsivgoulis G. Clinical, Neuroimaging, and Genetic Markers in Cerebral Amyloid Angiopathy-Related Inflammation: A Systematic Review and Meta-Analysis. Stroke 2023; 54:178-188. [PMID: 36453271 DOI: 10.1161/strokeaha.122.040671] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND There are limited data regarding the prevalence of distinct clinical, neuroimaging and genetic markers among patients diagnosed with cerebral amyloid angiopathy-related inflammation (CAA-ri). We sought to determine the prevalence of clinical, radiological, genetic and cerebrospinal fluid biomarker findings in patients with CAA-ri. METHODS A systematic review and meta-analysis of published studies including patients with CAA-ri was conducted to determine the prevalence of clinical, neuroimaging, genetic and cerebrospinal fluid biomarker findings. Subgroup analyses were performed based on (1) prospective or retrospective study design and (2) CAA-ri diagnosis with or without available biopsy. We pooled the prevalence rates using random-effects models and assessed the heterogeneity using Cochran-Q and I2-statistics. RESULTS We identified 4 prospective and 17 retrospective cohort studies comprising 378 patients with CAA-ri (mean age, 71.5 years; women, 52%). The pooled prevalence rates were as follows: cognitive decline at presentation 70% ([95% CI, 54%-84%]; I2=82%), focal neurological deficits 55% ([95% CI, 40%-70%]; I2=82%), encephalopathy 54% ([95% CI, 39%-68%]; I2=43%), seizures 37% ([95% CI, 27%-49%]; I2=65%), headache 31% ([95% CI, 22%-42%]; I2=58%), T2/fluid-attenuated inversion recovery-hyperintense white matter lesions 98% ([95% CI, 93%-100%]; I2=44%), lobar cerebral microbleeds 96% ([95% CI, 92%-99%]; I2=25%), gadolinium enhancing lesions 54% ([95% CI, 42%-66%]; I2=62%), cortical superficial siderosis 51% ([95% CI, 34%-68%]; I2=77%) and lobar macrohemorrhage 40% ([95% CI, 11%-73%]; I2=88%). The prevalence rate of the ApoE (Apolipoprotein E) ε4/ε4 genotype was 34% ([95% CI, 17%-53%]; I2=76%). Subgroup analyses demonstrated no differences in these prevalence rates based on study design and diagnostic strategy. CONCLUSIONS Cognitive decline was the most common clinical feature. Hyperintense T2/fluid-attenuated inversion recovery white matter lesions and lobar cerebral microbleeds were by far the most prevalent neuroimaging findings. Thirty-four percent of patients with CAA-ri have homozygous ApoE ε4/ε4 genotype and scarce data exist regarding the cerebrospinal fluid biomarkers and its significance in these patients.
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Affiliation(s)
- Aikaterini Theodorou
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Lina Palaiodimou
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.)
| | - Christina Zompola
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Efstathios Boviatsis
- Department of Neurosurgery (E.B.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Efthimios Dardiotis
- Neurology Department, University Hospital of Larissa, University of Thessaly, Greece (E.D.)
| | - Martha Spilioti
- First Department of Neurology, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece (M.S.)
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio, Italy (S.S.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, France (C.C.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
| | - George P Paraskevas
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
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9
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Okamoto K, Amari M, Ikeda M, Fukuda T, Suzuki K, Takatama M. A comparison of cerebral amyloid angiopathy in the cerebellum and CAA-positive occipital lobe of 60 brains from routine autopsies. Neuropathology 2022; 42:483-487. [PMID: 35747901 DOI: 10.1111/neup.12838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/29/2022] [Accepted: 05/15/2022] [Indexed: 12/15/2022]
Abstract
We semiquantitatively compared the frequency and severity of cerebral amyloid angiopathy (CAA) in the cerebellum and CAA-positive occipital lobe of 60 subjects from routine autopsies. In the 60 subjects with a CAA-positive occipital lobe, cerebellar CAA was observed in 29 subjects (48.3%), and the severity of cerebellar CAA was relatively mild compared with occipital lobe CAA. Capillary CAA was observed in the occipital lobe of 12 subjects and the cerebellum of three subjects. CAA-related vasculopathies were observed in the occipital lobe of 15 subjects and the cerebellum of two subjects. The severity of CAA-related vasculopathy was mild in both of these subjects. Amyloid-β plaques were observed in the occipital lobe of 54 subjects (90%) and the cerebellum of 16 subjects (26.7%). The severity of amyloid-β plaques in the cerebellum was mild compared with the occipital lobe. In summary, we confirmed that cerebellar CAA is frequently observed in the cerebellum but with a lower severity than CAA in the occipital lobe.
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Affiliation(s)
- Koichi Okamoto
- Department of Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Masakuni Amari
- Department of Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Masaki Ikeda
- Department of Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan.,Division of General Education (Neurology), Faculty of Health and Medical Care, Saitama Medical University, Hidaka, Japan
| | - Toshio Fukuda
- Department of Pathology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Keiji Suzuki
- Department of Pathology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Masamitsu Takatama
- Department of Internal Medicine, Geriatrics Research Institute and Hospital, Maebashi, Japan
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10
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Goeldlin M, Stewart C, Radojewski P, Wiest R, Seiffge D, Werring DJ. Clinical neuroimaging in intracerebral haemorrhage related to cerebral small vessel disease: contemporary practice and emerging concepts. Expert Rev Neurother 2022; 22:579-594. [PMID: 35850578 DOI: 10.1080/14737175.2022.2104157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION About 80% of all non-traumatic intracerebral haemorrhage (ICH) are caused by the sporadic cerebral small vessel diseases deep perforator arteriopathy (DPA, also termed hypertensive arteriopathy or arteriolosclerosis) and cerebral amyloid angiopathy (CAA), though these frequently co-exist in older people. Contemporary neuroimaging (MRI and CT) detects an increasing spectrum of haemorrhagic and non-haemorrhagic imaging biomarkers of small vessel disease which may identify the underlying arteriopathies. AREAS COVERED We discuss biomarkers for cerebral small vessel disease subtypes in ICH, and explore their implications for clinical practice and research. EXPERT OPINION ICH is not a single disease, but results from a defined range of vascular pathologies with important implications for prognosis and treatment. The terms "primary" and "hypertensive" ICH are poorly defined and should be avoided, as they encourage incomplete investigation and classification. Imaging-based criteria for CAA will show improved diagnostic accuracy, but specific imaging biomarkers of DPA are needed. Ultra-high-field 7T-MRI using structural and quantitative MRI may provide further insights into mechanisms and pathophysiology of small vessel disease. We expect neuroimaging biomarkers and classifications to allow personalized treatments (e.g. antithrombotic drugs) in clinical practice and to improve patient selection and monitoring in trials of targeted therapies directed at the underlying arteriopathies.
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Affiliation(s)
- Martina Goeldlin
- Department of Neurology, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Catriona Stewart
- Stroke Research Group, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Piotr Radojewski
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Switzerland
| | - Roland Wiest
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
| | - David J Werring
- Stroke Research Group, UCL Queen Square Institute of Neurology, London, United Kingdom
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11
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Hamaguchi T, Kim JH, Hasegawa A, Goto R, Sakai K, Ono K, Itoh Y, Yamada M. Exogenous Aβ seeds induce Aβ depositions in the blood vessels rather than the brain parenchyma, independently of Aβ strain-specific information. Acta Neuropathol Commun 2021; 9:151. [PMID: 34507620 PMCID: PMC8431898 DOI: 10.1186/s40478-021-01252-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 02/08/2023] Open
Abstract
Little is known about the effects of parenchymal or vascular amyloid β peptide (Aβ) deposition in the brain. We hypothesized that Aβ strain-specific information defines whether Aβ deposits on the brain parenchyma or blood vessels. We investigated 12 autopsied patients with different severities of Aβ plaques and cerebral amyloid angiopathy (CAA), and performed a seeding study using an Alzheimer’s disease (AD) mouse model in which brain homogenates derived from the autopsied patients were injected intracerebrally. Based on the predominant pathological features, we classified the autopsied patients into four groups: AD, CAA, AD + CAA, and less Aβ. One year after the injection, the pathological and biochemical features of Aβ in the autopsied human brains were not preserved in the human brain extract-injected mice. The CAA counts in the mice injected with all four types of human brain extracts were significantly higher than those in mice injected with PBS. Interestingly, parenchymal and vascular Aβ depositions were observed in the mice that were injected with the human brain homogenate from the less Aβ group. The Aβ and CAA seeding activities, which had significant positive correlations with the Aβ oligomer ratio in the human brain extracts, were significantly higher in the human brain homogenate from the less Aβ group than in the other three groups. These results indicate that exogenous Aβ seeds from different Aβ pathologies induced Aβ deposition in the blood vessels rather than the brain parenchyma without being influenced by Aβ strain-specific information, which might be why CAA is a predominant feature of Aβ pathology in iatrogenic transmission cases. Furthermore, our results suggest that iatrogenic transmission of Aβ pathology might occur due to contamination of brain tissues from patients with little Aβ pathology, and the development of inactivation methods for Aβ seeding activity to prevent iatrogenic transmission is urgently required.
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Potter T, Lioutas VA, Tano M, Pan A, Meeks J, Woo D, Seshadri S, Selim M, Vahidy F. Cognitive Impairment After Intracerebral Hemorrhage: A Systematic Review of Current Evidence and Knowledge Gaps. Front Neurol 2021; 12:716632. [PMID: 34512528 PMCID: PMC8429504 DOI: 10.3389/fneur.2021.716632] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Cognitive impairment (CI) is commonly observed after intracerebral hemorrhage (ICH). While a growing number of studies have explored this association, several evidence gaps persist. This review seeks to investigate the relationship between CI and ICH. Methods: A two-stage systematic review of research articles, clinical trials, and case series was performed. Initial search used the keywords ["Intracerebral hemorrhage" OR "ICH"] AND ["Cognitive Impairment" OR "Dementia OR "Cognitive Decline"] within the PubMed (last accessed November 3rd, 2020) and ScienceDirect (last accessed October 27th, 2020) databases, without publication date limits. Articles that addressed CI and spontaneous ICH were accepted if CI was assessed after ICH. Articles were rejected if they did not independently address an adult human population or spontaneous ICH, didn't link CI to ICH, were an unrelated document type, or were not written in English. A secondary snowball literature search was performed using reviews identified by the initial search. The Agency for Healthcare research and Quality's assessment tool was used to evaluate bias within studies. Rates of CI and contributory factors were investigated. Results: Search yielded 32 articles that collectively included 22,631 patients. Present evidence indicates a high rate of post-ICH CI (65-84%) in the acute phase (<4 weeks) which is relatively lower at 3 (17.3-40.2%) and 6 months (19-63.3%). Longer term follow-up (≥1 year) demonstrates a gradual increase in CI. Advanced age, female sex, and prior stroke were associated with higher rates of CI. Associations between post-ICH CI and cerebral microbleeds, superficial siderosis, and ICH volume also exist. Pre-ICH cognitive assessment was missing in 28% of included studies. The Mini Mental State Evaluation (44%) and Montreal Cognitive Assessment (16%) were the most common cognitive assessments, albeit with variable thresholds and definitions. Studies rarely (<10%) addressed racial and ethnic disparities. Discussion: Current findings suggest a dynamic course of post-ICH cognitive impairment that may depend on genetic, sociodemographic and clinical factors. Methodological heterogeneity prevented meta-analysis, limiting results. There is a need for the methodologies and time points of post-ICH cognitive assessments to be harmonized across diverse clinical and demographic populations.
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Affiliation(s)
- Thomas Potter
- Center for Outcomes Research, Houston Methodist Research Institute, Houston Methodist, Houston, TX, United States
| | | | - Mauricio Tano
- Center for Outcomes Research, Houston Methodist Research Institute, Houston Methodist, Houston, TX, United States
- Department of Nuclear Engineering, Texas A&M University, College Station, TX, United States
| | - Alan Pan
- Center for Outcomes Research, Houston Methodist Research Institute, Houston Methodist, Houston, TX, United States
| | - Jennifer Meeks
- Center for Outcomes Research, Houston Methodist Research Institute, Houston Methodist, Houston, TX, United States
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Farhaan Vahidy
- Center for Outcomes Research, Houston Methodist Research Institute, Houston Methodist, Houston, TX, United States
- Neurological Institute, Houston Methodist, Houston, TX, United States
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Sakai K, Noguchi‐Shinohara M, Ikeda T, Hamaguchi T, Ono K, Yamada M. Cerebrospinal fluid cytokines and metalloproteinases in cerebral amyloid angiopathy-related inflammation. Acta Neurol Scand 2021; 143:450-457. [PMID: 33247941 DOI: 10.1111/ane.13382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/06/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To clarify pathomechanisms of cerebral amyloid angiopathy-related inflammation/vasculitis (CAA-ri). METHODS We collected cerebrospinal fluid (CSF) samples of nine patients with CAA-ri of before (acute CAA-ri group) and after treatment (post-treatment CAA-ri group) and nine patients with CAA (CAA without inflammation group). We examined anti-amyloid β protein (Aβ) antibody titer by ELISA, and measured 27 Cytokines, nine matrix metalloproteinases (MMPs), and four tissue inhibitors of MMPs (TIMPs) by multiplexed fluorescent bead-based immunoassay. RESULTS We demonstrated TIMP-2 (median) in CSF of the acute CAA-ri group (30,994.49 pg/ml, p = 0.007) and the post-treatment CAA-ri group (36,430.97 pg/ml, p = 0.001) was significantly elevated compared to that of the CAA without inflammation group (22,013.58 pg/ml). TIMP-1 was also higher in the post-treatment CAA-ri group than that in the CAA without inflammation group (58,167.75 pg/ml vs. 45,770.03 pg/ml, p = 0.005). There was a significant positive correlation between TIMP-1 and anti-Aβ antibodies in CAA-ri (rs = 0.900, p = 0.037). Median MMP-2 tended to be higher in the acute and post-treatment CAA-ri groups (10,619.82 pg/ml and 8396.98 pg/ml, respectively) than in the CAA without inflammation group (4436.34 pg/ml). Platelet-derived growth factor (PDGF)-BB levels before treatment were higher than those after treatment (median, 12.66 pg/ml vs. 6.39 pg/ml; p = 0.011) and correlated with the titer of anti-Aβ antibodies (rs =0.900, p = 0.037). CONCLUSIONS Elevated levels of MMP-2, TIMP-1, and TIMP-2 might be related to the development of CAA-ri. Elevation of PDGF-BB could be a useful marker for clinical diagnosis of CAA-ri.
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Affiliation(s)
- Kenji Sakai
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Moeko Noguchi‐Shinohara
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Preemptive Medicine for Dementia Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Tokuhei Ikeda
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Neurology Ishikawa Prefectural Central Hospital Kanazawa Japan
| | - Tsuyoshi Hamaguchi
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Kenjiro Ono
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Neurology Showa University School of Medicine Tokyo Japan
| | - Masahito Yamada
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
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Abstract
ABSTRACT Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare but increasingly recognized subtype of CAA. CAA-RI consists of two subtypes: inflammatory cerebral amyloid angiopathy and amyloid β (Aβ)-related angiitis. Acute or subacute onset of cognitive decline or behavioral changes is the most common symptom of CAA-RI. Rapid progressive dementia, headache, seizures, or focal neurological deficits, with patchy or confluent hyperintensity on T2 or fluid-attenuated inversion recovery sequences and evidence of strictly lobar microbleeds or cortical superficial siderosis on susceptibility-weighted imaging imply CAA-RI. The gold standard for diagnosis is autopsy or brain biopsy. However, biopsy is invasive; consequently, most clinically diagnosed cases have been based on clinical and radiological data. Other diagnostic indexes include the apolipoprotein E ε4 allele, Aβ and anti-Aβ antibodies in cerebral spinal fluid and amyloid positron emission tomography. Many diseases with similar clinical manifestations should be carefully ruled out. Immunosuppressive therapy is effective both during initial presentation and in relapses. The use of glucocorticoids and immunosuppressants improves prognosis. This article reviews the pathology and pathogenesis, clinical and imaging manifestations, diagnostic criteria, treatment, and prognosis of CAA-RI, and highlights unsolved problems in the existing research.
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Saito S, Tanaka M, Satoh-Asahara N, Carare RO, Ihara M. Taxifolin: A Potential Therapeutic Agent for Cerebral Amyloid Angiopathy. Front Pharmacol 2021; 12:643357. [PMID: 33643053 PMCID: PMC7907591 DOI: 10.3389/fphar.2021.643357] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/15/2021] [Indexed: 12/22/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is characterized by the accumulation of β-amyloid (Aβ) in the walls of cerebral vessels, leading to complications such as intracerebral hemorrhage, convexity subarachnoid hemorrhage and cerebral microinfarcts. Patients with CAA-related intracerebral hemorrhage are more likely to develop dementia and strokes. Several pathological investigations have demonstrated that more than 90% of Alzheimer's disease patients have concomitant CAA, suggesting common pathogenic mechanisms. Potential causes of CAA include impaired Aβ clearance from the brain through the intramural periarterial drainage (IPAD) system. Conversely, CAA causes restriction of IPAD, limiting clearance. Early intervention in CAA could thus prevent Alzheimer's disease progression. Growing evidence has suggested Taxifolin (dihydroquercetin) could be used as an effective therapy for CAA. Taxifolin is a plant flavonoid, widely available as a health supplement product, which has been demonstrated to exhibit anti-oxidative and anti-inflammatory effects, and provide protection against advanced glycation end products and mitochondrial damage. It has also been shown to facilitate disassembly, prevent oligomer formation and increase clearance of Aβ in a mouse model of CAA. Disturbed cerebrovascular reactivity and spatial reference memory impairment in CAA are completely prevented by Taxifolin treatment. These results highlight the need for clinical trials on the efficacy and safety of Taxifolin in patients with CAA.
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Affiliation(s)
- Satoshi Saito
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masashi Tanaka
- Department of Physical Therapy, Health Science University, Fujikawaguchiko, Japan.,Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Noriko Satoh-Asahara
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
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Saito S, Ikeda Y, Ando D, Carare RO, Ishibashi-Ueda H, Ihara M. Cerebral Amyloid Angiopathy Presenting as Massive Subarachnoid Haemorrhage: A Case Study and Review of Literature. Front Aging Neurosci 2020; 12:538456. [PMID: 33240073 PMCID: PMC7683384 DOI: 10.3389/fnagi.2020.538456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 09/25/2020] [Indexed: 11/21/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is characterised by the progressive accumulation of β-amyloid (Aβ) in the walls of cerebral capillaries and arteries representing a major cause of haemorrhagic stroke including lobar intracerebral haemorrhage (ICH) and convexity subarachnoid haemorrhage (SAH). Haemorrhaging from CAA predominantly involves smaller arteries rather than arterial aneurysm. Restricted bleeding into the subarachnoid space in CAA results in asymptomatic or mild symptomatic SAH. Herein, we present an autopsied case of massive SAH related to CAA. An 89-year-old male with a history of mild Alzheimer’s disease (AD) and advanced pancreatic cancer with liver metastasis developed sudden onset of coma. Head CT illustrated ICH located in the right frontal lobe and right insula, as well as SAH bilaterally spreading from the basal cistern to the Sylvian fissure, with hydrocephalus and brain herniation. He died about 24 h after onset and the post-mortem examination showed no evidence of arterial aneurysm. The substantial accumulation of Aβ in the vessels around the haemorrhagic lesions led to the diagnosis of ICH related to CAA and secondary SAH, which may have been aggravated by old age and malignancy. This case suggests that CAA can cause severe SAH resembling aneurysmal origin and thus may be overlooked when complicated by atypical cerebral haemorrhage.
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Affiliation(s)
- Satoshi Saito
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Pediatric Dentistry, Graduate School of Dentistry, Osaka University, Suita, Japan.,Research Fellow of Japan Society for the Promotion of Science, Tokyo, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Daisuke Ando
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Roxana Octavia Carare
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
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