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Muir RT, Smith EE. The Spectrum of Cerebral Small Vessel Disease: Emerging Pathophysiologic Constructs and Management Strategies. Neurol Clin 2024; 42:663-688. [PMID: 38937035 DOI: 10.1016/j.ncl.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Cerebral small vessel disease (CSVD) is a spectrum of disorders that affect small arterioles, venules, cortical and leptomeningeal vessels, perivascular spaces, and the integrity of neurovascular unit, blood brain barrier, and surrounding glia and neurons. CSVD is an important cause of lacunar ischemic stroke and sporadic hemorrhagic stroke, as well as dementia-which will constitute some of the most substantive population and public health challenges over the next century. This article provides an overview of updated pathophysiologic frameworks of CSVD; discusses common and underappreciated clinical and neuroimaging manifestations of CSVD; and reviews emerging genetic risk factors linked to sporadic CSVD.
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Affiliation(s)
- Ryan T Muir
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 1N4, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta T2N 1N4, Canada
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 1N4, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta T2N 1N4, Canada.
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2
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Merella P, Casu G, Chessa P, Atzori E, Bandino S, Deiana G. When Atrial Fibrillation Meets Cerebral Amyloid Angiopathy: Current Evidence and Strategies. J Clin Med 2023; 12:7704. [PMID: 38137773 PMCID: PMC10743760 DOI: 10.3390/jcm12247704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Non-valvular atrial fibrillation (AF) and cerebral amyloid angiopathy (CAA) are two common diseases in elderly populations. Despite the effectiveness of oral anticoagulant therapy in cardioembolic stroke prevention, intracranial hemorrhage represents the most serious complication of these therapies. Cerebral amyloid angiopathy is one of the main risk factors for spontaneous intracranial bleeding, and this risk is highly increased by age and concomitant antithrombotic therapies. Cerebral amyloid angiopathy can be silent for years and then manifest with clinical features simulating TIA (TIA-mimics) or stroke in AF patients, pushing clinicians to rapidly start VKAs or DOACs, thus increasing the risk of intracranial bleeding if the diagnosis of CAA was unknown. Because the cerebral amyloid angiopathy is easily diagnosed with non-contrast MRI, suspecting the disease can avoid catastrophic complications. In this review, we will provide physicians managing anticoagulant therapies with key tips to familiarize themselves with cerebral amyloid angiopathy, with a focus on the possible clinical presentations and on the diagnostic criteria.
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Affiliation(s)
- Pierluigi Merella
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Gavino Casu
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
- Faculty of Medicine, University of Sassari, 07100 Sassari, Italy
| | - Paola Chessa
- Department of Pharmacy, San Francesco Hospital, 08100 Nuoro, Italy;
| | - Enrico Atzori
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Stefano Bandino
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Gianluca Deiana
- Department of Neurology and Stroke Unit, San Francesco Hospital, 08100 Nuoro, Italy;
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Sin MK, Zamrini E, Ahmed A, Nho K, Hajjar I. Anti-Amyloid Therapy, AD, and ARIA: Untangling the Role of CAA. J Clin Med 2023; 12:6792. [PMID: 37959255 PMCID: PMC10647766 DOI: 10.3390/jcm12216792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Anti-amyloid therapies (AATs), such as anti-amyloid monoclonal antibodies, are emerging treatments for people with early Alzheimer's disease (AD). AATs target amyloid β plaques in the brain. Amyloid-related imaging abnormalities (ARIA), abnormal signals seen on magnetic resonance imaging (MRI) of the brain in patients with AD, may occur spontaneously but occur more frequently as side effects of AATs. Cerebral amyloid angiopathy (CAA) is a major risk factor for ARIA. Amyloid β plays a key role in the pathogenesis of AD and of CAA. Amyloid β accumulation in the brain parenchyma as plaques is a pathological hallmark of AD, whereas amyloid β accumulation in cerebral vessels leads to CAA. A better understanding of the pathophysiology of ARIA is necessary for early detection of those at highest risk. This could lead to improved risk stratification and the ultimate reduction of symptomatic ARIA. Histopathological confirmation of CAA by brain biopsy or autopsy is the gold standard but is not clinically feasible. MRI is an available in vivo tool for detecting CAA. Cerebrospinal fluid amyloid β level testing and amyloid PET imaging are available but do not offer specificity for CAA vs amyloid plaques in AD. Thus, developing and testing biomarkers as reliable and sensitive screening tools for the presence and severity of CAA is a priority to minimize ARIA complications.
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Affiliation(s)
- Mo-Kyung Sin
- College of Nursing, Seattle University, Seattle, WA 98122, USA
| | | | - Ali Ahmed
- VA Medical Center, Washington, DC 20242, USA;
| | - Kwangsik Nho
- School of Medicine, Indianna University, Indianapolis, IN 46202, USA;
| | - Ihab Hajjar
- School of Medicine, University of Texas Southwestern, Dallas, TX 75390, USA;
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Takahashi Y, Oguchi K, Mochizuki Y, Takasone K, Ezawa N, Matsushima A, Katoh N, Yazaki M, Sekijima Y. Distribution and progression of cerebral amyloid angiopathy in early-onset V30M (p.V50M) hereditary ATTR amyloidosis. Amyloid 2023; 30:109-118. [PMID: 36178174 DOI: 10.1080/13506129.2022.2128331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is becoming the most common and serious complications in long-lived hereditary ATTR amyloidosis patients. It is therefore imperative to elucidate the characteristics of ATTR-type CAA and develop useful biomarkers. METHODS We enrolled 34 ATTRv amyloidosis patients with the V30M (p.V50M) variant for analysis with three-dimensional stereotactic surface projection z score imaging of Pittsburgh compound B (PiB)-PET. RESULTS Eight patients exhibited central nervous system (CNS) symptoms. Seven patients suffered transient focal neurologic episodes, and 2 patients each experienced cerebellar haemorrhages or cognitive decline. The amount of 11C-PiB accumulation increased as a function of disease duration. 11C-PiB-PET abnormalities were seen at 8 years from onset and were associated with CNS manifestations from 12 years. The annual increase rate of the standardised uptake value ratio (SUVR) in female patients was significantly higher than in male patients. CNS amyloid deposition started in the upper middle surface of the cerebellar cortex, and then spread out over the entire surface of the cerebellum, Sylvian fissure, and anterior part of the longitudinal fissure of the cerebrum. CONCLUSIONS PiB-PET is a useful biomarker for the early detection and treatment evaluation of ATTR-type CAA. Female gender is associated with more rapid progression of ATTR-type CAA.
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Affiliation(s)
- Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Yusuke Mochizuki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ken Takasone
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoki Ezawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Akira Matsushima
- Department of Neurology, JA Nagano Koseiren Kakeyu Misayama Rehabilitation Center Kakeyu Hospital, Matsumoto, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Masahide Yazaki
- Department of Biomedical Laboratory Sciences, Shinshu University School of Health Sciences, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Jisenkai Brain Imaging Research Center, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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Tabaee Damavandi P, Storti B, Fabin N, Bianchi E, Ferrarese C, DiFrancesco JC. Epilepsy in cerebral amyloid angiopathy: an observational retrospective study of a large population. Epilepsia 2023; 64:500-510. [PMID: 36515439 DOI: 10.1111/epi.17489] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a major cause of spontaneous intracranial hemorrhage in older adults. Epilepsy represents a possible sequela of the disease. To date, studies on epilepsy in CAA are lacking, and the few data available mainly focus on CAA-related inflammation (CAA-ri), the inflammatory form of the disease. METHODS In this retrospective observational study, we consecutively recruited CAA patients observed over a time span of 10 years, collecting demographic, clinical, and instrumental data. Significant baseline characteristics were evaluated as potential risk factors for the development of epilepsy in the CAA population, and in the subgroups of CAA-ri and CAA without inflammatory reaction (CAA-nri). The effect of potential risk factors for epilepsy was measured as odds ratio with 95% confidence interval. RESULTS Within 96 recruited CAA cases, 33 (34.4%) developed epilepsy during follow-up (median = 13.5 months). The prevalent type of seizure was focal (81.3%); 12.1% of the epileptic patients presented status epilepticus, and 6.1% developed drug-resistant epilepsy. Electroencephalographic traces revealed slow and epileptic discharge activity in the majority of epileptic patients, but also in those without epilepsy. The presence of focal or disseminated cortical superficial siderosis (cSS) was associated with an increased risk of epilepsy in the CAA-nri group, and the association with CAA-ri and epilepsy was present in the overall population. SIGNIFICANCE Epilepsy is a common manifestation during the course of CAA, where CAA-ri and cSS represent predisposing factors for the development of seizures. These data suggest the importance of a deep characterization of CAA patients, to better select those more prone to develop epilepsy.
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Affiliation(s)
- Payam Tabaee Damavandi
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Benedetta Storti
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Natalia Fabin
- Laboratory of Epidemiological and Clinical Cardiology, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Elisa Bianchi
- Neurological Disorders, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Carlo Ferrarese
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
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A case of transthyretin-related cerebral amyloid angiopathy. The other side of hereditary transthyretin amyloidosis. Acta Neurol Belg 2022; 122:571-573. [PMID: 35040071 DOI: 10.1007/s13760-021-01854-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/12/2021] [Indexed: 11/01/2022]
Abstract
The target organs for familial transthyretin amyloidosis are typically the nerves, the heart or even the eyes due to the accumulation of amyloid deposits. Less frequently, these deposits can occur within the central nervous system and drive a specific phenotype of cerebral amyloid angiopathy. We report the case of a 72-year-old woman showing evidence of cerebral amyloid angiopathy, in a context of hereditary transthyretin amyloidosis (hATTR) due to p.(Ser77Tyr) mutation of the TTR gene. Her cognitive assessment on a two-year follow-up was remarkably steady. A very limited number of patients with hereditary transthyretin amyloidosis associated with a cerebral amyloid angiopathy have been reported. Few characteristics could distinguish them from classic cerebral amyloid angiopathy, and more data are needed to highlight specific features. Screening for peripheral neuropathy should be considered for patients referred to memory clinic for atypical cerebral amyloid angiopathy.
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Uneus EI, Wilhelmsson C, Bäckström D, Anan I, Wixner J, Pilebro B, Riklund K, Ögren M, Ögreen M, Axelsson J, Suhr OB, Sundström T. Cerebellar and Cerebral Amyloid Visualized by [18F]flutemetamol PET in Long-Term Hereditary V30M (p.V50M) Transthyretin Amyloidosis Survivors. Front Neurol 2022; 13:816636. [PMID: 35317351 PMCID: PMC8934387 DOI: 10.3389/fneur.2022.816636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Hereditary transthyretin (ATTRv) amyloidosis caused by the V30M (p. V50M) mutation is a fatal, neuropathic systemic amyloidosis. Liver transplantation has prolonged the survival of patients and central nervous system (CNS) complications, attributed to amyloid angiopathy caused by CNS synthesis of variant transthyretin, have emerged. The study aimed to ascertain amyloid deposition within the brain in long-term ATTRv amyloidosis survivors with neurological symptoms from the CNS. Methods A total of 20 patients with ATTR V30M having symptoms from the CNS and a median disease duration of 16 years (8–25 years) were included in this study. The cognitive and peripheral nervous functions were determined for 18 patients cross-sectionally at the time of the investigation. Amyloid brain deposits were examined by [18F]flutemetamol PET/CT. Five patients with Alzheimer's disease (AD) served as positive controls. Result 60% of the patients with ATTRv had a pathological Z-score in the cerebellum, compared to only 20% in the patients with AD. 75% of the patients with transient focal neurological episodes (TFNEs) displayed a pathological uptake only in the cerebellum. Increased cerebellar uptake was related to an early age of onset of the ATTRv disease. 55% of the patients with ATTRv had a pathological Z-score in the global cerebral region compared to 100% of the patients with AD. Conclusion Amyloid deposition within the brain after long-standing ATTRv amyloidosis is common, especially in the cerebellum. A cerebellar amyloid uptake profile seems to be related to TFNE symptoms.
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Affiliation(s)
- Erica Irene Uneus
- Section of Neurology, Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Christer Wilhelmsson
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - David Bäckström
- Section of Neurology, Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Intissar Anan
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Björn Pilebro
- Department of Public Health and Clinical Medicine, Heart Centre, Cardiology, Umeå University, Umeå, Sweden
| | - Katrine Riklund
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Mattias Ögren
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Margareta Ögreen
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Jan Axelsson
- Department of Radiation Sciences, Radiation Physics, Umeå University, Umeå, Sweden
| | - Ole B. Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- *Correspondence: Ole B. Suhr
| | - Torbjörn Sundström
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
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Thomsen AV, Sørensen MT, Ashina M, Hougaard A. Symptomatic migraine: A systematic review to establish a clinically important diagnostic entity. Headache 2021; 61:1180-1193. [PMID: 34254302 DOI: 10.1111/head.14187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine if a clinical presentation indistinguishable from migraine can occur due to an underlying condition or pathology, that is, "symptomatic migraine." BACKGROUND It is currently not clear whether migraine truly can be caused by an underlying condition or pathology. Characterization of the etiology and clinical features of possible symptomatic migraine is of significant clinical importance and further may help elucidate the pathophysiology of migraine. METHODS We devised operational diagnostic criteria for "symptomatic migraine" and "possible symptomatic migraine" requiring strong evidence for a causal relation between underlying cause and migraine symptoms adhering strictly to diagnostic criteria. PubMed was searched for case reports of symptomatic migraine from inception to March 2020. Only articles published in English or German were included. No restrictions were placed on study design. Relevant references in the articles were also included. Papers were systematically reviewed by two independent reviewers for detailed clinical features of migraine as well as the proposed underlying conditions and the effects of treatment of these conditions. RESULTS Our search retrieved 1726 items. After screening, 109 papers comprising 504 cases were reviewed in detail. Eleven patients with migraine with aura (MWA) fulfilled our working criteria for symptomatic migraine, and 39 patients fulfilled our criteria for possible symptomatic migraine. The most common etiologies of symptomatic migraine were arteriovenous malformations, carotid stenosis, dissection or aneurysm, brain infarctions, meningioma, and various intra-axial tumors. CONCLUSIONS Symptomatic MWA, indistinguishable from idiopathic MWA, may occur due to cortical lesions or microembolization. We found no clear evidence supporting the existence of symptomatic migraine without aura although we did identify possible cases. Our findings are limited by the available literature, and we suggest that prospective studies are needed.
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Affiliation(s)
- Andreas Vinther Thomsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Morten Togo Sørensen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Anders Hougaard
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
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Jäkel L, De Kort AM, Klijn CJM, Schreuder FHBM, Verbeek MM. Prevalence of cerebral amyloid angiopathy: A systematic review and meta-analysis. Alzheimers Dement 2021; 18:10-28. [PMID: 34057813 PMCID: PMC9290643 DOI: 10.1002/alz.12366] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 01/05/2023]
Abstract
Reported prevalence estimates of sporadic cerebral amyloid angiopathy (CAA) vary widely. CAA is associated with cognitive dysfunction and intracerebral hemorrhage, and linked to immunotherapy‐related side‐effects in Alzheimer's disease (AD). Given ongoing efforts to develop AD immunotherapy, accurate estimates of CAA prevalence are important. CAA can be diagnosed neuropathologically or during life using MRI markers including strictly lobar microbleeds. In this meta‐analysis of 170 studies including over 73,000 subjects, we show that in patients with AD, CAA prevalence based on pathology (48%) is twice that based on presence of strictly lobar cerebral microbleeds (22%); in the general population this difference is three‐fold (23% vs 7%). Both methods yield similar estimated prevalences of CAA in cognitively normal elderly (5% to 7%), in patients with intracerebral hemorrhage (19% to 24%), and in patients with lobar intracerebral hemorrhage (50% to 57%). However, we observed large heterogeneity among neuropathology and MRI protocols, which calls for standardized assessment and reporting of CAA.
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Affiliation(s)
- Lieke Jäkel
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Alzheimer Centre, Radboud University Medical Cente, Nijmegen, The Netherlands
| | - Anna M De Kort
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Alzheimer Centre, Radboud University Medical Cente, Nijmegen, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Alzheimer Centre, Radboud University Medical Cente, Nijmegen, The Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Alzheimer Centre, Radboud University Medical Cente, Nijmegen, The Netherlands
| | - Marcel M Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Alzheimer Centre, Radboud University Medical Cente, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Smith EE, Charidimou A, Ayata C, Werring DJ, Greenberg SM. Cerebral Amyloid Angiopathy-Related Transient Focal Neurologic Episodes. Neurology 2021; 97:231-238. [PMID: 34016709 PMCID: PMC8356377 DOI: 10.1212/wnl.0000000000012234] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/19/2021] [Indexed: 12/22/2022] Open
Abstract
Transient focal neurologic episodes (TFNEs) are brief disturbances in motor, somatosensory, visual, or language functions that can occur in patients with cerebral amyloid angiopathy (CAA) and may be difficult to distinguish from TIAs or other transient neurologic syndromes. They herald a high rate of future lobar intracerebral hemorrhage, making it imperative to differentiate them from TIAs to avoid potentially dangerous use of antithrombotic drugs. Cortical spreading depression or depolarization triggered by acute or chronic superficial brain bleeding, a contributor to brain injury in other neurologic diseases, may be the underlying mechanism. This review discusses diagnosis, pathophysiology, and management of CAA-related TFNEs.
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Affiliation(s)
- Eric E Smith
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK.
| | - Andreas Charidimou
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Cenk Ayata
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - David J Werring
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
| | - Steven M Greenberg
- From the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Hemorrhagic Stroke Research Program (A.C., S.M.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School; Stroke Service and Neurovascular Research Lab (C.A.), Department of Neurology, Massachusetts General Hospital, Boston; and Stroke Research Centre (D.J.W.), University College London Queen Square Institute of Neurology, UK
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11
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Koutroulou I, Tsivgoulis G, Tsalikakis D, Karacostas D, Grigoriadis N, Karapanayiotides T. Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review. Front Neurol 2020; 11:281. [PMID: 32411074 PMCID: PMC7198765 DOI: 10.3389/fneur.2020.00281] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/25/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction: Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies. Methods: We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events. Results: In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5–3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0–2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, p < 0.0001, OR = 2.6 with 95% CI = 2.0–3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6–2.5), but not TTE (53.3 vs. 37.5%, p = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0–2.8) but not TTE (10.4 vs. 7.8%, p = 0.75) or TCD (22.8 vs. 20.1%, p = 0.56). Conclusions: Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.
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Affiliation(s)
- Ioanna Koutroulou
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Dimitris Karacostas
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Charidimou A. Cerebral amyloid angiopathy-related transient focal neurological episodes (CAA-TFNEs): A well-defined clinical-radiological syndrome. J Neurol Sci 2019; 406:116496. [DOI: 10.1016/j.jns.2019.116496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/28/2022]
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13
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Vales-Montero M, García-Pastor A, Iglesias-Mohedano AM, Esteban-de Antonio E, Salgado-Cámara P, García-Domínguez JM, Vázquez-Alén P, Díaz-Otero F, Fernández-Bullido Y, Gil-Núñez A. Cerebral amyloid angiopathy-related transient focal neurological episodes: A transient ischemic attack mimic with an increased risk of intracranial hemorrhage. J Neurol Sci 2019; 406:116452. [PMID: 31525529 DOI: 10.1016/j.jns.2019.116452] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 08/05/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transient focal neurological episodes (TFNEs) are a recently recognized clinical presentation of cerebral amyloid angiopathy (CAA). Our aim was to describe the clinical and radiological features of a series of patients with AS. METHODS We included 11 patients presenting with recurrent transient focal neurological symptoms and radiological features related to CAA. RESULTS Mean age was 76,6 and 5 patients were women. All patients reported transient, stereotyped, and recurrent episodes (6 patients had >10 episodes). Gradual spread of the symptoms was recorded in 9 patients. Initially, 3 patients were misdiagnosed as having recurrent transient ischemic attack (TIA), 6 as having seizures, and 2 as having both. Two patients were prescribed antiplatelet therapy. A cerebral MRI with T2* gradient-recalled echo sequence revealed cortical superficial siderosis (cSS) in 5 patients, cortical microbleeds in 1 patient, and both features in 5 cases. After a median follow-up of 36 months, intracranial hemorrhage (ICH) was recorded in 4 patients. All 4 had cSS in the previous cerebral MRI, and 1 was on antiplatelet therapy. CONCLUSION CAA-related TFNEs are an underdiagnosed entity, often mimicking TIA, seizures, or migraine aura. This misdiagnosis can lead to the prescription of antiplatelet or anticoagulant therapy, which increases the risk of ICH. Our results suggest that cSS might be a radiological marker that is closely related to an increased risk of bleeding. A T2* gradient-recalled echo MRI should be performed in elderly patients with transient focal neurological symptoms suggestive of CAA.
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Affiliation(s)
- Marta Vales-Montero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Andrés García-Pastor
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain.
| | - Ana María Iglesias-Mohedano
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Ester Esteban-de Antonio
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Paula Salgado-Cámara
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - José Manuel García-Domínguez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Pilar Vázquez-Alén
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Fernando Díaz-Otero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Yolanda Fernández-Bullido
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Antonio Gil-Núñez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
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Carmona-Iragui M, Videla L, Lleó A, Fortea J. Down syndrome, Alzheimer disease, and cerebral amyloid angiopathy: The complex triangle of brain amyloidosis. Dev Neurobiol 2019; 79:716-737. [PMID: 31278851 DOI: 10.1002/dneu.22709] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/04/2019] [Accepted: 07/02/2019] [Indexed: 11/07/2022]
Abstract
Down syndrome (DS) is the main genetic cause of intellectual disability worldwide. The overexpression of the Amyloid Precursor Protein, present in chromosome 21, leads to β-amyloid deposition that results in Alzheimer disease (AD) and, in most cases, also to cerebral amyloid angiopathy (CAA) neuropathology. People with DS invariably develop the neuropathological hallmarks of AD at the age of 40, and they are at an ultra high risk for suffering AD-related cognitive impairment thereafter. In the general population, cerebrovascular disease is a significant contributor to AD-related cognitive impairment, while in DS remains understudied. This review describes the current knowledge on cerebrovascular disease in DS and reviews the potential biomarkers that could be useful in the future studies, focusing on CAA. We also discuss available evidence on sporadic AD or other genetically determined forms of AD. We highlight the urgent need of large biomarker-characterized cohorts, including neuropathological correlations, to study the exact contribution of CAA and related vascular factors that play a role in cognition and occur with aging, their characterization and interrelationships. DS represents a unique context in which to perform these studies as this population is relatively protected from some conventional vascular risk factors and they develop significant CAA, DS represents a particular atheroma-free model to study AD-related vascular pathologies. Only deepening on these underlying mechanisms, new preventive and therapeutic strategies could be designed to improve the quality of life of this population and their caregivers and lead to new avenues of treatment also in the general AD population.
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Affiliation(s)
- María Carmona-Iragui
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau- Biomedical Research Institute Sant Pau- Universitat Autònoma de Barcelona, Barcelona, Spain
- Barcelona Down Medical Center, Fundació Catalana Síndrome de Down, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Laura Videla
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau- Biomedical Research Institute Sant Pau- Universitat Autònoma de Barcelona, Barcelona, Spain
- Barcelona Down Medical Center, Fundació Catalana Síndrome de Down, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Alberto Lleó
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau- Biomedical Research Institute Sant Pau- Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Juan Fortea
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau- Biomedical Research Institute Sant Pau- Universitat Autònoma de Barcelona, Barcelona, Spain
- Barcelona Down Medical Center, Fundació Catalana Síndrome de Down, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
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Chen SJ, Tsai HH, Tsai LK, Tang SC, Lee BC, Liu HM, Yen RF, Jeng JS. Advances in cerebral amyloid angiopathy imaging. Ther Adv Neurol Disord 2019; 12:1756286419844113. [PMID: 31105769 PMCID: PMC6501479 DOI: 10.1177/1756286419844113] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/25/2019] [Indexed: 11/16/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a cerebral small vessel disease caused by β -amyloid (Aβ) deposition at the leptomeningeal vessel walls. It is a common cause of spontaneous intracerebral hemorrhage and a frequent comorbidity in Alzheimer’s disease. The high recurrent hemorrhage rate in CAA makes it very important to recognize this disease to avoid potential harmful medication. Imaging studies play an important role in diagnosis and research of CAA. Conventional computed tomography and magnetic resonance imaging (MRI) methods reveal anatomical alterations, and remains as the most reliable tool in identifying CAA according to modified Boston criteria. The vascular injuries of CAA result in both hemorrhagic and ischemic manifestations and related structural changes on MRI, including cerebral microbleeds, cortical superficial siderosis, white matter hyperintensity, MRI-visible perivascular spaces, and cortical microinfarcts. As imaging techniques advance, not only does the resolution of conventional imaging improve, but novel skills in functional and molecular imaging studies also enable in vivo analysis of vessel physiological changes and underlying pathology. These modern tools help in early detection of CAA and may potentially serve as sensitive outcome markers in future clinical trials. In this article, we reviewed past studies of CAA focusing on utilization of various conventional and novel imaging techniques in both research and clinical aspects.
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Affiliation(s)
- Szu-Ju Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, No. 87, Neijiang Street, Taipei, 10845, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Bo-Chin Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Hon-Man Liu
- Department of Medical Imaging, Fu-Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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16
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Nakajima M, Takeuchi Y, Nagao Y, Masuda T, Yamashita T, Yonehara T, Terasaki T, Ando Y. Comparison of clinical features in transient focal neurological episodes between hereditary transthyretin type and Aβ type cerebral amyloid angiopathy. Amyloid 2019; 26:81-82. [PMID: 31343286 DOI: 10.1080/13506129.2019.1583199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Makoto Nakajima
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan.,b Division of Research for Cerebrovascular Diseases, Kumamoto University Hospital , Kumamoto , Japan
| | - Yosuke Takeuchi
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Yoichiro Nagao
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan.,c Department of Neurology, Kumamoto Red Cross Hospital , Kumamoto , Japan
| | - Teruaki Masuda
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Taro Yamashita
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
| | - Toshiro Yonehara
- d Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital , Kumamoto , Japan
| | - Tadashi Terasaki
- c Department of Neurology, Kumamoto Red Cross Hospital , Kumamoto , Japan
| | - Yukio Ando
- a Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
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17
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Hostettler IC, Werring DJ. Acute Convexity Subarachnoid Hemorrhage: What the Neurosurgeon Needs to Know. World Neurosurg 2018; 123:184-187. [PMID: 30580060 DOI: 10.1016/j.wneu.2018.12.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - David John Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, United Kingdom
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18
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Terrin A, Toldo G, Ermani M, Mainardi F, Maggioni F. When migraine mimics stroke: A systematic review. Cephalalgia 2018; 38:2068-2078. [PMID: 29661036 DOI: 10.1177/0333102418767999] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Migraine with aura may mimic an acute ischemic stroke, so that an improper administration of thrombolytic treatment can expose migrainous patients to severe adverse effects. METHODS This systematic review quantifies the relevance of migraine with aura among stroke mimics, checking for thrombolysis' safety in these patients. We reviewed the literature after 1995, distinguishing from studies dealing with stroke mimics treated with systemic thrombolysis and those who were not treated with systemic thrombolysis. RESULTS Migraine with aura is responsible for 1.79% (CI 95% 0.82-3.79%) of all the emergency Stroke Unit evaluations and it represents 12.24% (CI 95% 6.34-22.31%) of stroke mimics in the group not treated with systemic thrombolysis. 6.65% (CI 95% 4.32-9.78%) of systemic thrombolysis administrations are performed in patients without an acute ischemic stroke. Migraine with aura is responsible for 17.91% of these (CI 95% 13.29-23.71%). The reported rate of adverse events seems extremely low (0.01%). CONCLUSION Migraine with aura is the third most common stroke mimic, following seizures and psychiatric disorders; it is responsible for about 18% of all improper thrombolytic treatments. Despite the absence of strong supporting data, thrombolysis in migraine with aura seems to be a procedure with an extremely low risk of adverse events.
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Affiliation(s)
- Alberto Terrin
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Giulia Toldo
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Mario Ermani
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | | | - Ferdinando Maggioni
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
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Sharma R, Dearaugo S, Infeld B, O'Sullivan R, Gerraty RP. Cerebral amyloid angiopathy: Review of clinico-radiological features and mimics. J Med Imaging Radiat Oncol 2018; 62:451-463. [PMID: 29604173 DOI: 10.1111/1754-9485.12726] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 01/02/2023]
Abstract
Cerebral amyloid angiopathy (CAA) is an important cause of lobar intracerebral haemorrhage (ICH) in the elderly, but has other clinico-radiological manifestations. In the last two decades, certain magnetic resonance imaging (MRI) sequences, namely gradient-recalled echo imaging and the newer and more sensitive susceptibility-weighted imaging, have been utilised to detect susceptibility-sensitive lesions such as cerebral microbleeds and cortical superficial siderosis. These can be utilised sensitively and specifically by the Modified Boston Criteria to make a diagnosis of CAA without the need for 'gold-standard' histopathology from biopsy. However, recently, other promising MRI biomarkers of CAA have been described which may further increase precision of radiological diagnosis, namely chronic white matter ischaemia, cerebral microinfarcts and lobar lacunes, cortical atrophy, and increased dilated perivascular spaces in the centrum semiovale. However, the radiological manifestations of CAA, as well as their clinical correlates, may have other aetiologies and mimics. It is important for the radiologist to be aware of these clinico-radiological features and mimics to accurately diagnose CAA. This is increasingly important in a patient demographic that has a high prevalence for use of antiplatelet and antithrombotic medications for other comorbidities which inherently carries an increased risk of ICH in patients with CAA.
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Affiliation(s)
- Rohit Sharma
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Stephanie Dearaugo
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Bernard Infeld
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Richard O'Sullivan
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Healthcare Imaging Services, Melbourne, Victoria, Australia
| | - Richard P Gerraty
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
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20
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Lin CM, Arishima H, Kikuta KI, Naiki H, Kitai R, Kodera T, Matsuda K, Hashimoto N, Isozaki M, Tsunetoshi K, Neishi H, Higashino Y, Akazawa A, Arai H, Yamada S. Pathological examination of cerebral amyloid angiopathy in patients who underwent removal of lobar hemorrhages. J Neurol 2018; 265:567-577. [PMID: 29356971 DOI: 10.1007/s00415-018-8740-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 10/05/2017] [Accepted: 01/06/2018] [Indexed: 02/07/2023]
Abstract
Cerebral amyloid angiopathy (CAA) is a degenerative disorder characterized by amyloid-β (Aβ) deposition in the brain microvessels. CAA is also known to contribute not only to cortical microbleeds but also lobar hemorrhages. This retrospective study examined CAA pathologically in patients who underwent direct surgeries for lobar hemorrhage. Thirty-three patients with lobar hemorrhage underwent open surgery with biopsy from 2007 to 2016 in our hospital. Cortical tissues over hematomas obtained surgically were pathologically examined using hematoxylin, eosin stain, and anti-Aβ antibody to diagnose CAA. We also investigated the advanced degree of CAA and clinical features of each patient with lobar hemorrhage. In the 33 patients, 4 yielded specimens that were insufficient to evaluate CAA pathologically. Twenty-four of the remaining 29 patients (82.8%) were pathologically diagnosed with CAA. The majority of CAA-positive patients had moderate or severe CAA based on a grading scale to estimate the advanced degree of CAA. About half of the CAA-positive patients had hypertension, and four took anticoagulant or antiplatelet agents. In five patients who were not pathologically diagnosed with CAA, one had severe liver function disorder, three had uncontrollable hypertension, and one had no obvious risk factor. Our pathological findings suggest that severe CAA with vasculopathic change markedly contributes to lobar hemorrhage. The coexistence of severe CAA and risk factors such as hypertension, anticoagulants or antiplatelets may readily induce lobar hemorrhage.
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Affiliation(s)
- Chien-Min Lin
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei City, Taiwan
| | - Hidetaka Arishima
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Ken-Ichiro Kikuta
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hironobu Naiki
- Department of Pathology, University of Fukui, Fukui, Japan
| | - Ryuhei Kitai
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Toshiaki Kodera
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Ken Matsuda
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Norichika Hashimoto
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Makoto Isozaki
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kenzo Tsunetoshi
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hiroyuki Neishi
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Yoshifumi Higashino
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Ayumi Akazawa
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hiroshi Arai
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Shinsuke Yamada
- Department of Neurosurgery, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
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21
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Cerebral amyloid angiopathy – The modified Boston criteria in clinical practice. J Neurol Sci 2018; 384:55-57. [DOI: 10.1016/j.jns.2017.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 10/22/2017] [Accepted: 11/16/2017] [Indexed: 01/13/2023]
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22
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Prevalence and clinical characteristics of cortical superficial siderosis in patients with acute stroke. J Neurol 2017; 264:2413-2419. [PMID: 29063241 DOI: 10.1007/s00415-017-8646-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
Cortical superficial siderosis (cSS) is a pathologic and radiologic diagnosis of hemosiderin deposition in subpial brain layers. However, cSS has not been fully studied in patients with acute stroke. Here, we investigated the prevalence of cSS in patients with acute stroke and analyzed the relationship between cSS and different clinical and neuroimaging characteristics. From September 2014 through June 2016, consecutive patients with acute stroke who were admitted to our department were retrospectively investigated. We analyzed the prevalence of cSS and the associations between cSS and risk factors, the topographic distribution of cerebral microbleeds (CMBs), and the severity of white matter lesions (WMLs). In total, 739 patients (589 patients with ischemic stroke/transient ischemic stroke [IS/TIA] and 150 with intracerebral hemorrhage [ICH]; mean age, 71.4 years) were enrolled. We identified cSS in six (1.0%) patients with IS/TIA and seven (4.7%) patients with ICH. The presence of cSS was associated with ICH (P < 0.0001), WMLs (P = 0.0105), and lobar and non-lobar CMBs (both P < 0.0001); no associations between cSS and age, sex, cardiovascular risk factors, IS subtype classification, or antiplatelet and anticoagulant therapy were found. In a multivariable logistic regression analysis, high numbers of lobar CMBs (≥ 2; odds ratio, 11.03; 95% confidence interval, 2.03-205.40; P = 0.0029) were independently associated with cSS. Furthermore, cSS was often located near lobar CMBs. Our results suggest that cSS is prevalent in ICH and is independently associated with lobar CMBs; however, no associations between cSS and other risk factors or comorbidities were observed.
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Barbay M, Taillia H, Nedelec-Ciceri C, Arnoux A, Puy L, Wiener E, Canaple S, Lamy C, Godefroy O, Roussel M. Vascular cognitive impairment: Advances and trends. Rev Neurol (Paris) 2017; 173:473-480. [DOI: 10.1016/j.neurol.2017.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/15/2017] [Indexed: 10/18/2022]
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Farid K, Charidimou A, Baron JC. Amyloid positron emission tomography in sporadic cerebral amyloid angiopathy: A systematic critical update. NEUROIMAGE-CLINICAL 2017; 15:247-263. [PMID: 28560150 PMCID: PMC5435601 DOI: 10.1016/j.nicl.2017.05.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 01/07/2023]
Abstract
Sporadic cerebral amyloid angiopathy (CAA) is a very common small vessel disease of the brain, showing preferential and progressive amyloid-βdeposition in the wall of small arterioles and capillaries of the leptomeninges and cerebral cortex. CAA now encompasses not only a specific cerebrovascular pathological trait, but also different clinical syndromes - including spontaneous lobar intracerebral haemorrhage (ICH), dementia and ‘amyloid spells’ - an expanding spectrum of brain parenchymal MRI lesions and a set of diagnostic criteria – the Boston criteria, which have resulted in increasingly detecting CAA during life. Although currently available validated diagnostic criteria perform well in multiple lobar ICH, a formal diagnosis is currently lacking unless a brain biopsy is performed. This is partly because in practice CAA MRI biomarkers provide only indirect evidence for the disease. An accurate diagnosis of CAA in different clinical settings would have substantial impact for ICH risk stratification and antithrombotic drug use in elderly people, but also for sample homogeneity in drug trials. It has recently been demonstrated that vascular (in addition to parenchymal) amyloid-βdeposition can be detected and quantified in vivo by positron emission tomography (PET) amyloid tracers. This non-invasive approach has the potential to provide a molecular signature of CAA, and could in turn have major clinical impact. However, several issues around amyloid-PET in CAA remain unsettled and hence its diagnostic utility is limited. In this article we systematically review and critically appraise the published literature on amyloid-PET (PiB and other tracers) in sporadic CAA. We focus on two key areas: (a) the diagnostic utility of amyloid-PET in CAA and (b) the use of amyloid-PET as a window to understand pathophysiological mechanism of the disease. Key issues around amyloid-PET imaging in CAA, including relevant technical aspects are also covered in depth. A total of six small-scale studies have addressed (or reported data useful to address) the diagnostic utility of late-phase amyloid PET imaging in CAA, and one additional study dealt with early PiB images as a proxy of brain perfusion. Across these studies, amyloid PET imaging has definite diagnostic utility (currently tested only in probable CAA): it helps rule out CAA if negative, whether compared to healthy controls or to hypertensive deep ICH controls. If positive, however, differentiation from underlying incipient Alzheimer's disease (AD) can be challenging and so far, no approach (regional values, ratios, visual assessment) seems sufficient and specific enough, although early PiB data seem to hold promise. Based on the available evidence reviewed, we suggest a tentative diagnostic flow algorithm for amyloid-PET use in the clinical setting of suspected CAA, combining early- and late-phase PiB-PET images. We also identified ten mechanistic amyloid-PET studies providing early but promising proof-of-concept data on CAA pathophysiology and its various manifestations including key MRI lesions, cognitive impairment and large scale brain alterations. Key open questions that should be addressed in future studies of amyloid-PET imaging in CAA are identified and highlighted. CAA is a major cause of brain haemorrhage and cognitive impairment in aged subjects. Without brain biopsy, its current diagnosis largely relies on indirect MRI markers. Amyloid PET may provide a non-invasive molecular signature to formally diagnose CAA. Based on our review, amyloid PET has excellent sensitivity but specificity is unclear. Amyloid PET is also useful to investigate mechanisms underlying CAA manifestations.
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Affiliation(s)
- Karim Farid
- Department of Nuclear Medicine, Martinique University Hospital, Fort-de-France, Martinique
| | - Andreas Charidimou
- Massachusetts General Hospital, Department of Neurology, Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Jean-Claude Baron
- U894, Centre Hospitalier Sainte Anne, Sorbonne Paris Cité, Paris, France.
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Arshi A, Sharim J, Restrepo L. Recurrent Focal Neurological Symptoms and Cortical Siderosis. Neurohospitalist 2017; 7:104-105. [PMID: 28400907 DOI: 10.1177/1941874416656732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Armin Arshi
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin Sharim
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lucas Restrepo
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Zerna C, Modi J, Bilston L, Shoamanesh A, Coutts SB, Smith EE. Cerebral Microbleeds and Cortical Superficial Siderosis in Patients Presenting With Minor Cerebrovascular Events. Stroke 2016; 47:2236-41. [PMID: 27507863 DOI: 10.1161/strokeaha.116.013418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/07/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient focal neurological episodes occur in cerebral amyloid angiopathy (CAA) and can mimic transient ischemic attack (TIA). Risk factors and outcomes of minor ischemic stroke or TIA might differ in patients with and without cerebral microbleeds (CMBs), including CAA-consistent lobar CMB. METHODS Baseline magnetic resonance imaging (MRI) was analyzed for CMBs and cortical superficial siderosis in 416 patients in the prospective computed tomography and MRI in the CATCH study (Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Clinical symptoms, baseline characteristics, recurrence, and 90-day modified Rankin Scale were prospectively collected. MRI white-matter hyperintensity was measured using the Fazekas scale. RESULTS CMBs were detected in 65 (15.6%) and cortical superficial siderosis in 11 patients (2.6%). Lobar CMBs were present in 49 (11.8%). In multivariable logistic regression adjusted for risk factors and age, subcortical Fazekas score was associated with lobar CMB (odds ratio, 2.07; 95% confidence interval, 1.23-3.48; P=0.006). Forty-two patients (10.1%) had lobar-only CMBs with or without cortical superficial siderosis consistent with modified Boston criteria for possible/probable CAA. The possible/probable CAA pattern was not predictive of recurrent TIA (odds ratio, 0.42; 95% confidence interval, 0.05-3.31; P=0.41), stroke (odds ratio, 1.24; 95% confidence interval, 0.26-5.99; P=0.79), or 90-day modified Rankin Scale score ≥2 (odds ratio, 1.38; 95% confidence interval, 0.62-3.07; P=0.42). CONCLUSIONS CMBs in TIA and minor stroke are moderately common but do not predict recurrence or 90-day outcome. CAA-related transient focal neurological episodes and TIA have overlapping clinical symptoms, suggesting that MRI may be needed for differentiation.
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Affiliation(s)
- Charlotte Zerna
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.)
| | - Jayesh Modi
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.)
| | - Lisa Bilston
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.)
| | - Ashkan Shoamanesh
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.)
| | - Shelagh B Coutts
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.)
| | - Eric E Smith
- From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.).
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Sekijima Y, Yazaki M, Oguchi K, Ezawa N, Yoshinaga T, Yamada M, Yahikozawa H, Watanabe M, Kametani F, Ikeda SI. Cerebral amyloid angiopathy in posttransplant patients with hereditary ATTR amyloidosis. Neurology 2016; 87:773-81. [PMID: 27466465 DOI: 10.1212/wnl.0000000000003001] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 04/01/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the prevalence and clinical features of posttransplant CNS symptoms in patients with hereditary ATTR amyloidosis and their Pittsburgh compound B (PiB)-PET imaging correlates. METHODS We monitored prevalence and type of CNS symptoms in 53 consecutive posttransplant patients with hereditary ATTR amyloidosis. (11)C-PiB-PET was performed in 15 patients with various disease durations. We also analyzed pathologic and biochemical characteristics of ATTR amyloid deposition in the brain of a posttransplant patient. RESULTS Transient focal neurologic episodes (TFNEs) attributed to ATTR-type cerebral amyloid angiopathy (CAA) were found in 11.3% of posttransplant hereditary ATTR amyloidosis patients. TFNE occurred on average 16.8 years after onset of the disease. Patients with longer duration of illness (≥10 years) showed increased (11)C-PiB retention in the brain. The (11)C-PiB accumulation pattern in hereditary ATTR amyloidosis was unique and different from those in Alzheimer disease or Aβ-type CAA. In the autopsy case, ATTR amyloid deposition was mainly localized to leptomeningeal vessels and leptomeninges of the brain. Amyloid fibrils in the brain were almost completely composed of variant transthyretin (TTR). CONCLUSIONS TFNE due to ATTR-type CAA occurred frequently in posttransplant patients with long disease durations. (11)C-PiB-PET is a useful diagnostic tool for ATTR-type CAA. ATTR amyloid deposition in the CNS, as measured by PiB-PET, was detected approximately 10 years before onset of TFNE.
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Affiliation(s)
- Yoshiki Sekijima
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan.
| | - Masahide Yazaki
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Kazuhiro Oguchi
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Naoki Ezawa
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Tsuneaki Yoshinaga
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Mitsunori Yamada
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Hiroyuki Yahikozawa
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Masahide Watanabe
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Fuyuki Kametani
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
| | - Shu-Ichi Ikeda
- From the Departments of Medicine (Neurology and Rheumatology) (Y.S., M.Y., N.E., T.Y., S.-i.I.) and Brain Disease Research (M.Y.), Shinshu University School of Medicine; Institute for Biomedical Sciences (Y.S., M.Y., S.-i.I.), Shinshu University; Jisenkai Brain Imaging Research Center (Y.S., K.O.); Departments of Neurology (H.Y.) and Pathology (M.W.), Nagano Red Cross Hospital; and Department of Dementia and Higher Brain Function (F.K.), Tokyo Metropolitan Institute of Medical Science, Japan
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Ellis JA, Banu M, Hossain SS, Singh-Moon R, Lavine SD, Bruce JN, Joshi S. Reassessing the Role of Intra-Arterial Drug Delivery for Glioblastoma Multiforme Treatment. JOURNAL OF DRUG DELIVERY 2015; 2015:405735. [PMID: 26819758 PMCID: PMC4706947 DOI: 10.1155/2015/405735] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/16/2015] [Indexed: 12/16/2022]
Abstract
Effective treatment for glioblastoma (GBM) will likely require targeted delivery of several specific pharmacological agents simultaneously. Intra-arterial (IA) delivery is one technique for targeting the tumor site with multiple agents. Although IA chemotherapy for glioblastoma (GBM) has been attempted since the 1950s, the predicted benefits remain unproven in clinical practice. This review focuses on innovative approaches to IA drug delivery in treating GBM. Guided by novel in vitro and in vivo optical measurements, newer pharmacokinetic models promise to better define the complex relationship between background cerebral blood flow and drug injection parameters. Advanced optical technologies and tracers, unique nanoparticles designs, new cellular targets, and rational drug formulations are continuously modifying the therapeutic landscape for GBM. Personalized treatment approaches are emerging; however, such tailored approaches will largely depend on effective drug delivery techniques and on the ability to simultaneously deliver multidrug regimens. These new paradigms for tumor-selective drug delivery herald dramatic improvements in the effectiveness of IA chemotherapy for GBM. Therefore, within this context of so-called "precision medicine," the role of IA delivery for GBM is thoroughly reassessed.
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Affiliation(s)
- Jason A. Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Matei Banu
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Shaolie S. Hossain
- Department of Molecular Cardiology, Texas Heart Institute, Houston, TX 77030, USA
| | - Rajinder Singh-Moon
- School of Engineering and Applied Science, Columbia University, New York, NY 10032, USA
| | - Sean D. Lavine
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Jeffrey N. Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Shailendra Joshi
- Department of Anesthesiology, Columbia University Medical Center, New York, NY 10032, USA
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Charidimou A, Linn J, Vernooij MW, Opherk C, Akoudad S, Baron JC, Greenberg SM, Jäger HR, Werring DJ. Cortical superficial siderosis: detection and clinical significance in cerebral amyloid angiopathy and related conditions. Brain 2015; 138:2126-39. [PMID: 26115675 DOI: 10.1093/brain/awv162] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/17/2015] [Indexed: 01/13/2023] Open
Abstract
Cortical superficial siderosis describes a distinct pattern of blood-breakdown product deposition limited to cortical sulci over the convexities of the cerebral hemispheres, sparing the brainstem, cerebellum and spinal cord. Although cortical superficial siderosis has many possible causes, it is emerging as a key feature of cerebral amyloid angiopathy, a common and important age-related cerebral small vessel disorder leading to intracerebral haemorrhage and dementia. In cerebral amyloid angiopathy cohorts, cortical superficial siderosis is associated with characteristic clinical symptoms, including transient focal neurological episodes; preliminary data also suggest an association with a high risk of future intracerebral haemorrhage, with potential implications for antithrombotic treatment decisions. Thus, cortical superficial siderosis is of relevance to neurologists working in neurovascular, memory and epilepsy clinics, and neurovascular emergency services, emphasizing the need for appropriate blood-sensitive magnetic resonance sequences to be routinely acquired in these clinical settings. In this review we focus on recent developments in neuroimaging and detection, aetiology, prevalence, pathophysiology and clinical significance of cortical superficial siderosis, with a particular emphasis on cerebral amyloid angiopathy. We also highlight important areas for future investigation and propose standards for evaluating cortical superficial siderosis in research studies.
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Affiliation(s)
- Andreas Charidimou
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Linn
- 3 Department of Neuroradiology, University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Meike W Vernooij
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Christian Opherk
- 5 Institute for Stroke and Dementia Research, Ludwig Maximilians University, Munich, and Department of Neurology, SLK-Kliniken, Heilbronn, Germany
| | - Saloua Akoudad
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Jean-Claude Baron
- 6 UMR 894 INSERM-Université Paris 5, Sorbonne Paris Cité, Paris, France
| | - Steven M Greenberg
- 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Hans Rolf Jäger
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 7 Lysholm Department of Neuroradiology, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Werring
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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Charidimou A. Elderly and forgetful with transient neurological spells: A story of two amyloids? J Neurol Sci 2015; 351:1-2. [DOI: 10.1016/j.jns.2015.02.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
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Yamada M. Cerebral amyloid angiopathy: emerging concepts. J Stroke 2015; 17:17-30. [PMID: 25692104 PMCID: PMC4325636 DOI: 10.5853/jos.2015.17.1.17] [Citation(s) in RCA: 235] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/15/2014] [Accepted: 12/24/2014] [Indexed: 12/15/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) involves cerebrovascular amyloid deposition and is classified into several types according to the amyloid protein involved. Of these, sporadic amyloid β-protein (Aβ)-type CAA is most commonly found in older individuals and in patients with Alzheimer's disease (AD). Cerebrovascular Aβ deposits accompany functional and pathological changes in cerebral blood vessels (CAA-associated vasculopathies). CAA-associated vasculopathies lead to development of hemorrhagic lesions [lobar intracerebral macrohemorrhage, cortical microhemorrhage, and cortical superficial siderosis (cSS)/focal convexity subarachnoid hemorrhage (SAH)], ischemic lesions (cortical infarction and ischemic changes of the white matter), and encephalopathies that include subacute leukoencephalopathy caused by CAA-associated inflammation/angiitis. Thus, CAA is related to dementia, stroke, and encephalopathies. Recent advances in diagnostic procedures, particularly neuroimaging, have enabled us to establish a clinical diagnosis of CAA without brain biopsies. Sensitive magnetic resonance imaging (MRI) methods, such as gradient-echo T2* imaging and susceptibility-weighted imaging, are useful for detecting cortical microhemorrhages and cSS. Amyloid imaging with amyloid-binding positron emission tomography (PET) ligands, such as Pittsburgh Compound B, can detect CAA, although they cannot discriminate vascular from parenchymal amyloid deposits. In addition, cerebrospinal fluid markers may be useful, including levels of Aβ40 for CAA and anti-Aβ antibody for CAA-related inflammation. Moreover, cSS is closely associated with transient focal neurological episodes (TFNE). CAA-related inflammation/angiitis shares pathophysiology with amyloid-related imaging abnormalities (ARIA) induced by Aβ immunotherapies in AD patients. This article reviews CAA and CAA-related disorders with respect to their epidemiology, pathology, pathophysiology, clinical features, biomarkers, diagnosis, treatment, risk factors, and future perspectives.
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Affiliation(s)
- Masahito Yamada
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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Ahn SH, Lee JH, Kim JS. An elderly patient with recurrent episodes of hemi-paresthesia. Cerebral amyloid angiopathy (CAA). Eur Neurol 2015; 73:171-2. [PMID: 25592722 DOI: 10.1159/000367843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 08/24/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Sung H Ahn
- Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea
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Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia 2014; 35:894-911. [PMID: 25505036 DOI: 10.1177/0333102414560635] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/27/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Migraine is one of the most common chronic neurological disorders. In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in older individuals that mimic transient ischemic attacks. There has not been an update on the underlying nature and etiology of late-life migraine accompanimentsd since the original description. PURPOSE The purpose of this article is to provide a comprehensive and extensive review of the late-life migraine accompaniments including the epidemiology, clinical characteristics, differential diagnosis, and treatment. METHODS Literature searches were performed in MEDLINE®, PubMed, Cochrane Library, and EMBASE databases for publications from 1941 to July 2014. The search terms "Migraine accompaniments," "Late life migraine," "Migraine with aura," "Typical aura without headache," "Migraine equivalents," "Acephalic migraine," "Elderly migraine," and "Transient neurological episodes" were used. CONCLUSION Late-life onset of migraine with aura is not rare in clinical practice and can occur without headache, especially in elderly individuals. Visual symptoms are the most common presentation, followed respectively by sensory, aphasic, and motor symptoms. Gradual evolution, the march of transient neurological deficits over several minutes and serial progression from one symptom to another in succession are typical clinical features for late-life migraine accompaniments. Transient neurological disturbances in migraine aura can mimic other serious conditions and can be easily misdiagnosed. Careful clinical correlation and appropriate investigations are essential to exclude secondary causes. Treatments are limited and still inconsistent.
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Affiliation(s)
- Kiratikorn Vongvaivanich
- Comprehensive Headache Clinic, Neuroscience Center, Bangkok Hospital, Bangkok Hospital Group, Thailand
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Coates R, Bell SM, Coley S, Blackburn DJ. Cerebral amyloid angiopathy: amyloid spells and cortical superficial siderosis. Pract Neurol 2014; 15:124-6. [PMID: 25359331 DOI: 10.1136/practneurol-2014-000952] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Rebecca Coates
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon M Bell
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stuart Coley
- Department of NeuroRadiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel J Blackburn
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK Department of Neurology, Sheffield Institute of Translation Neuroscience (SITraN), University of Sheffield, Sheffield, UK
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Affiliation(s)
- Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Center for Human Genetic Research, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston; and Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Jonathan Rosand
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Center for Human Genetic Research, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston; and Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.
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Affiliation(s)
- Magdy H Selim
- From the Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.H.S.); and Stroke Unit, Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.).
| | - Carlos A Molina
- From the Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.H.S.); and Stroke Unit, Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.)
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Abstract
Cerebral amyloid angiopathy is a commonly occurring condition that is not familiar to most clinicians. A common presenting feature may be transient focal neurological symptoms leading to the potential for clinical misdiagnosis as transient ischaemic attack. This may result in the inappropriate use of anti-platelets and anticoagulants or radiological misdiagnosis. It is also being increasingly recognised as an important cause of spontaneous intracerebral haemorrhage and cognitive impairment in the elderly. Cerebral amyloid angiopathy can be diagnosed based on clinical and radiological findings, but clinicians need a high index of suspicion to ensure appropriate investigations are requested. In this article we aim to cover the pathophysiology, clinical findings, radiological appearances and approach to management of cerebral amyloid angiopathy.
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Charidimou A, Peeters AP, Jäger R, Fox Z, Vandermeeren Y, Laloux P, Baron JC, Werring DJ. Cortical superficial siderosis and intracerebral hemorrhage risk in cerebral amyloid angiopathy. Neurology 2013; 81:1666-73. [PMID: 24107862 DOI: 10.1212/01.wnl.0000435298.80023.7a] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether cortical superficial siderosis (cSS) on MRI, especially if disseminated (involving more than 3 sulci), increases the risk of future symptomatic lobar intracerebral hemorrhage (ICH) in cerebral amyloid angiopathy (CAA). METHODS European multicenter cohort study of 118 patients with CAA (104 with baseline symptomatic lobar ICH) diagnosed according to the Boston criteria. We obtained baseline clinical, MRI, and follow-up data on symptomatic lobar ICH. Using Kaplan-Meier and Cox regression analyses, we investigated cSS and ICH risk, adjusting for known confounders. RESULTS During a median follow-up time of 24 months (interquartile range 9-44 months), 23 of 118 patients (19.5%, 95% confidence interval [CI]: 12.8%-27.8%) experienced symptomatic lobar ICH. Any cSS and disseminated cSS were predictors of time until first or recurrent ICH (log-rank test: p = 0.0045 and p = 0.0009, respectively). ICH risk at 4 years was 25% (95% CI: 7.6%-28.3%) for patients without siderosis; 28.9% (95% CI: 7.7%-76.7%) for patients with focal siderosis; and 74% (95% CI: 44.1%-95.7%) for patients with disseminated cSS (log-rank test: p = 0.0031). In Cox regression models, any cSS and disseminated cSS were both independently associated with increased lobar ICH risk, after adjusting for ≥ 2 microbleeds and age (hazard ratio: 2.53; 95% CI: 1.05-6.15; p = 0.040 and hazard ratio: 3.16; 95% CI: 1.35-7.43; p = 0.008, respectively). These results remained consistent in sensitivity analyses including only patients with symptomatic lobar ICH at baseline. CONCLUSIONS Our findings indicate that cSS, particularly if disseminated, is associated with an increased risk of symptomatic lobar ICH in CAA. cSS may help stratify future bleeding risk in CAA, with implications for prognosis and treatment.
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Affiliation(s)
- Andreas Charidimou
- From the Stroke Research Group, Department of Brain Repair and Rehabilitation (A.C., D.J.W.), and Lysholm Department of Neuroradiology (R.J.), UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Department of Neurology (A.P.P.), Cliniques Universitaires UCL Saint Luc, Brussels, Belgium; Department of Brain Repair and Rehabilitation (R.J.), and Biomedical Research Centre, UCL and the Education Unit (Z.F.), UCL Institute of Neurology, Queen Square, London, UK; Department of Neurology, CHU Mont-Godinne (Y.V., P.L.), and Institute of Neuroscience (Y.V., P.L.), Université Catholique de Louvain, Brussels, Belgium; Department of Clinical Neurosciences (J.-C.B.), University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; and UMR 894 INSERM-Université Paris 5, Sorbonne Paris Cité, Paris, France
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Hurford R, Charidimou A, Werring D. Symptomatic lobar intracerebral haemorrhage preceded by transient focal neurological episodes. BMJ Case Rep 2013; 2013:bcr-2013-008687. [PMID: 23661651 DOI: 10.1136/bcr-2013-008687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the case of a symptomatic intracerebral haemorrhage (ICH) in an elderly woman, secondary to cerebral amyloid angiopathy (CAA), and present the relevant imaging. A few months before, our patient experienced multiple, stereotyped, brief episodes of spreading paraesthesias, which were considered to be transient ischaemic attacks (TIAs) and treated with antithrombotic agents. In this case report, we explore CAA, a highly prevalent but under-recognised form of small vessel cerebrovascular disease and common cause of ICH. We then briefly discuss the clinical significance of transient focal neurological episodes in the context of CAA, as potential warning signs of future ICH. An important clinical message is that misdiagnosis of CAA-related focal neurological symptoms as TIAs (and prescribing antithrombotic drugs) could lead to potentially avoidable ICH. We also provide the current evidence base for the acute and secondary prevention treatment of patients with lobar ICH attributed to CAA, and discuss the prognosis.
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Affiliation(s)
- Robert Hurford
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Charidimou A, Baron JC, Werring DJ. Cerebral Amyloid Angiopathy and Transient Focal Neurological Episodes. Cerebrovasc Dis 2013; 36:245-6. [DOI: 10.1159/000353989] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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