Surgical risk of hemorrhage in cerebral amyloid angiopathy

Association of antithrombotic therapy with postoperative rebleeding in patients with cerebral amyloid angiopathy

BACKGROUND

Cerebral amyloid angiopathy is a common cause of subcortical hemorrhage in older adults. Although open hematoma removal may be performed for severe subcortical hemorrhage, its safety in patients with cerebral amyloid angiopathy has not been established, and postoperative rebleeding may occur. Therefore, this study aimed to investigate factors associated with postoperative rebleeding.

METHODS

Out of 145 consecutive patients who had undergone craniotomy for surgical removal of subcortical intracerebral hemorrhage between April 2010 and August 2019 at a single institution in Japan, we examined 109 patients with subcortical hemorrhage who met the inclusion criteria. After excluding 30 patients whose tissue samples were unsuitable for the study, the final study cohort comprised 79 patients.

RESULTS

Of the 79 patients, 50 (63%) were diagnosed with cerebral amyloid angiopathy (cerebral amyloid angiopathy group) and 29 (37%) were not diagnosed with noncerebral amyloid angiopathy (noncerebral amyloid angiopathy group). Postoperative rebleeding occurred in 12 patients (24%) in the cerebral amyloid angiopathy group and in 2 patients (7%) in the noncerebral amyloid angiopathy group. Preoperative prothrombin time-international normalized ratio and intraoperative bleeding volume were significantly associated with postoperative rebleeding in the cerebral amyloid angiopathy group (odds ratio = 42.4, 95% confidence interval = 1.14-1578; p = 0.042 and odds ratio = 1.005, 95% confidence interval = 1.001-1.008; p = 0.007, respectively).

CONCLUSIONS

Patients with cerebral amyloid angiopathy-related cerebral hemorrhage who are receiving antithrombotic therapy, particularly warfarin therapy, are at a high risk of postoperative rebleeding.

TRIAL REGISTRATION

Registry and Registration Number of the study: 19-220, 2019/12/23, retrospectively registered.

Subdural Hemorrhage from Cerebral Amyloid Angiopathy-Related Intracerebral Hemorrhage: A Risk Factor for Postoperative Hemorrhage

OBJECTIVE

Surgical treatment for cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH) is controversial. A subset of CAA-related ICH with associated subdural hemorrhage (SDH) has been reported. This study aimed to evaluate clinical results and surgical outcomes of this type of ICH with associated SDH.

METHODS

Study participants included 98 patients with CAA-related ICH who met Boston criteria. Patients were divided into an SDH group and a control (no SDH) group. Clinical and neuroimaging features and surgical outcomes of the 2 groups were compared.

RESULTS

Lobular shape of hematoma was found significantly more often in the SDH group (65.7% [23/35]) compared with the control group (25.4% [16/63]; P < 0.001). Subarachnoid hemorrhage was found significantly more often in the SDH group (34.3% [12/35]) compared with the control group (7.9% [5/63]; P = 0.001). The rate of postoperative hemorrhage was significantly higher in the SDH group (61.5% [8/13]) than in the control group (16.2% [6/37]; P = 0.006). The frequency of occurrence of postoperative hemorrhage was significantly higher in the SDH group (13/13) than in the control group (6/37; P = 0.017). A good surgical outcome occurred in none (0/12) of the patients in the SDH group, whereas a good surgical outcome occurred in 51.9% (14/27) of patients in the control group (P = 0.006).

CONCLUSIONS

Patients with CAA-related ICH with associated SDH more frequently have postoperative hemorrhage and have a worse surgical outcome. These findings are useful in choosing therapeutic methods and preoperative planning of surgical strategy.

Intracerebral hemorrhage due to cerebral amyloid angiopathy after head injury: Report of a case and review of the literature

Cerebral amyloid angiopathy (CAA) is an important cause of spontaneous intracerebral hemorrhage in the elderly. A few case reports of CAA-related intracerebral hemorrhage after head injury, usually following a fall, have been published. More rarely, it may occur in the setting of a traffic accident, with only four cases having been reported. We describe a case of CAA-related intracerebral hemorrhage in an 88-year-old man injured in a road traffic accident. The patient died 14 h after the accident. Autopsy examination revealed a left frontoparietal hematoma and CAA of most of the small leptomeningeal and cortical arteries, as well as several capillaries, predominantly in the parietal and occipital lobes. Except for bruises in the frontal and zygomatic regions, elbow and forearm, to the left, there were no skull fractures or traumatic lesions in other parts of the body. We review the literature on CAA-related intracerebral hemorrhage associated with head injury. CAA-related intracerebral hemorrhage after head injury may occur due to a minor trauma, minor and severe falls, or in the setting of a traffic accident. However, even in this last condition, it seems to happen mostly in patients who had a mild to moderate head injury. These facts show that replacement of the contractile components of the arterial tunica media by amyloid renders the affected cerebral blood vessels more vulnerable to head injury associated with acceleration and deceleration, independently of the severity of the dynamic loading acting on the head.

Clinico-Radiological Characteristics and Pathological Diagnosis of Cerebral Amyloid Angiopathy-Related Intracerebral Hemorrhage

OBJECTIVE

We aim to clarify the clinico-radiological characteristics of cerebral amyloid angiopathy-related intracerebral hemorrhage and to investigate the efficacy of pathological diagnosis using biopsy specimens.

METHOD

We retrospectively reviewed 253 consecutive patients with cortico-subcortical hemorrhage who had been admitted to Aizawa Hospital between January 2006 and July 2013. We had performed craniotomy and hematoma evacuation in 48 patients, as well as biopsy of the evacuated hematoma, cerebral parenchyma adjacent to the hematoma, or both, and they were classified according to the histological results (positive or negative for vascular amyloid deposition) and to the Boston criteria. We compared the clinico-radiological characteristics of cerebral amyloid angiopathy-related intracerebral hemorrhage. We also investigated the detection rate of cerebral amyloid angiopathy with respect to the origins of the specimens.

RESULTS

Pathological examination revealed that 22 subjects were positive for vascular amyloid. The number of the cerebral microbleeds located in the deep or infratentorial region was significantly larger in the negative group than in the positive group (P <.05). There was no significant difference in the distribution of lobar cerebral microbleeds and in the prevalence of hypertension. In the probable cerebral amyloid angiopathy-related intracerebral hemorrhage patients, the probability of having vascular amyloid detected by biopsy of both hematoma and parenchyma was 100%. Rebleeding in the postoperative periods was observed in 2 cases (9.1%) of the positive group.

CONCLUSIONS

Our results demonstrate the importance and safety of biopsy simultaneously performed with hematoma evacuation. Deep or infratentorial microbleeds are less correlated with cerebral amyloid angiopathy-related intracerebral hemorrhage than with noncerebral amyloid angiopathy-related intracerebral hemorrhage.

Recurrent cerebral amyloid angiopathy-related hemorrhage

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

Cerebral amyloid angiopathy-associated intracerebral hemorrhage: pathology and management

Amyloid angiopathy-associated intracerebral hemorrhage (ICH) comprises 12%-15% of lobar ICH in the elderly. This growing population has an increasing incidence of thrombolysis-related hemorrhages, causing the management of hemorrhages associated with cerebral amyloid angiopathy (CAA) to take center stage. A concise reference assimilating the pathology and management of this clinical entity does not exist. Amyloid angiopathy-associated hemorrhages are most often solitary, but the natural history often progresses to include multifocal and recurrent hemorrhages. Compared with other causes of ICH, patients with CAA-associated hemorrhages have a lower mortality rate but an increased risk of recurrence. Unlike hypertensive arteriolar hemorrhages that occur in penetrating subcortical vessels, CAA-associated hemorrhages are superficial in location due to preferential involvement of vessels in the cerebral cortex and meninges. This feature makes CAA-associated hemorrhages easier to access surgically. In this paper, the authors discuss 3 postulates regarding the pathogenesis of amyloid hemorrhages, as well as the established clinicopathological classification of amyloid angiopathy and CAA-associated ICH. Common inheritance patterns of familial CAA with hemorrhagic strokes are discussed along with the role of genetic screening in relatives of patients with CAA. The radiological characteristics of CAA are described with specific attention to CAA-associated microhemorrhages. The detection of these microhemorrhages may have important clinical implications on the administration of anticoagulation and antiplatelet therapy in patients with probable CAA. Poor patient outcome in CAA-associated ICH is associated with dementia, increasing age, hematoma volume and location, initial Glasgow Coma Scale score, and intraventricular extension. The surgical management strategies for amyloid hemorrhages are discussed with a review of published surgical case series and their outcomes with a special attention to postoperative hemorrhage.

Postoperative outcome of cerebral amyloid angiopathy-related lobar intracerebral hemorrhage: case series and systematic review

BACKGROUND

Despite its accessible superficial location, the indication for surgical evacuation in cases of lobar intracerebral hemorrhage (LICH) suspected to be related to cerebral amyloid angiopathy (CAA) is controversial because of advanced patient age and concerns about postoperative hemostasis.

OBJECTIVE

To examine factors associated with postoperative outcome in CAA-related LICH.

METHODS

Review of consecutive patients with pathologically proven CAA who underwent LICH evacuation at Saint Marys Hospital, Rochester, Minnesota, between 1987 and 2006. End points were length of stay and postoperative outcome at discharge and last follow-up using the Glasgow Outcome Scale. We also performed a systematic review of all published studies evaluating the outcome of surgically treated CCA-related LICH published between 1984 and 2010.

RESULTS

We identified 23 patients with CAA-related LICH treated surgically. Favorable outcome (Glasgow Outcome Scale >3) at discharge was noted in 5 patients (22%), and at 6- to 12-month follow-up (n = 15) in 7 patients (47%). Three (13%) died in the hospital, including 1 of 4 patients with postoperative hemorrhage. Intraventricular hemorrhage (IVH) was associated with poor outcome at discharge. Older age (≥75 years), history of hypertension, and degree of preoperative midline shift were associated with more prolonged length of stay. In our systematic review, we identified 14 studies including 278 cases. Overall mortality rate was 25%, and poor postoperative outcome was associated with older age, IVH, and preoperative dementia.

CONCLUSION

Neurosurgical evacuation may be performed with acceptable safety in patients with CAA-related LICH. A systematic literature review indicates that older age, preexistent dementia, and presurgical IVH portend poor postoperative outcome.

Clinical features of non-hypertensive lobar intracerebral hemorrhage related to cerebral amyloid angiopathy

BACKGROUND AND PURPOSE

The present study aims to clarify the clinical features of non-hypertensive cerebral amyloid angiopathy-related lobar intracerebral hemorrhage (CAA-L-ICH).

METHODS

We investigated clinical, laboratory, and neuroimaging findings in 41 patients (30, women; 11, men) with pathologically supported CAA-L-ICH from 303 non-hypertensive Japanese patients aged >OR=55, identified via a nationwide survey as symptomatic CAA-L-ICH.

RESULTS

The mean age of patients at onset of CAA-L-ICH was 73.2 +/- 7.4 years; the number of patients increased with age. The corrected female-to-male ratio for the population was 2.2, with significant female predominance. At onset, 7.3% of patients received anti-platelet therapy. In brain imaging studies, the actual frequency of CAA-L-ICHs was higher in the frontal and parietal lobes; however, after correcting for the estimated cortical volume, the parietal lobe was found to be the most frequently affected. CAA-L-ICH recurred in 31.7% of patients during the average 35.3-month follow-up period. The mean interval between intracerebral hemorrhages (ICHs) was 11.3 months. The case fatality rate was 12.2% at 1 month and 19.5% at 12 months after initial ICH. In 97.1% of patients, neurosurgical procedures were performed without uncontrollable intraoperative or post-operative hemorrhage.

CONCLUSIONS

Our study revealed the clinical features of non-hypertensive CAA-L-ICH, including its parietal predilection, which will require further study with a larger number of patients with different ethnic backgrounds.

Outcome of cerebral amyloid angiopathic brain haemorrhage

BACKGROUND

Abnormal amyloid protein can be deposited in the wall of cerebral arteries leading to fragility and intracerebral haematoma in patients with cerebral amyloid angiopathy. Diagnosis can be done only histologically. The indication of surgically treating intracerebral haemorrhage caused by amyloid angiopathy is controversial. There are studies showing a high mortality and a high rate of recurrent bleeding. Others show almost no recurrent bleeding and a very low mortality and a third party states that even when recurrent intracerebral haemorrhage occurs, re-evacuation should be performed. In the present retrospective study a population of 99 patients suffering from cerebral amyloid angiopathy-related cerebral haemorrhage has been studied, to investigate the surgical outcome.

METHOD

Ninety-nine patients were histologically diagnosed with cerebral amyloid angiopathy in our department from 1991-2004. The outcome has been established by the Glascow Outcome Score.

FINDINGS

It could be shown that intraventricular bleeding and age >75 years increased the mortality after operative evacuation. Recurrent bleeding occurred in 22% of patients. After re-evacuation at least half of the patients survived leading to the suggestion to re-operate a recurrent bleeding since patients have a chance to survive even when the Glascow Outcome Score is 3. The overall mortality in the observed population was 16% and 11% had a very good neurological recovery based on a Glascow Outcome Score of 4-5. The operative outcome in amyloid angiopathy related intracerebral haemorrhage is similar to this of intracerebral haemorrhage induced by other causes like hypertensive bleeding.

CONCLUSIONS

Possible cerebral amyloid angiopathy is no contraindication for evacuation of brain-haematoma, and especially not in patients younger than 75 years old without an intraventricular haemorrhage.

Sporadic cerebral amyloid angiopathy: pathology, clinical implications, and possible pathomechanisms

Cerebral amyloid angiopathy (CAA) was observed for the first time nearly 100 years ago and systematically described in 1938. It is a common finding in elderly individuals, defined by beta-amyloid peptide (Abeta) depositions in cerebral blood vessels, and associated with Alzheimer's disease (AD). A variety of genetic mutations cause hereditary forms of CAA; in this review, however, only the sporadic variant of CAA is considered. In CAA, Abeta depositions primarily occur in the abluminal portion of the tunica media, and with increasing severity all layers of the blood vessel wall are infiltrated and an additional spread of Abeta into the surrounding neuropil may be seen (i.e., dyshoric changes). CAA is most pronounced in the occipital lobe and its distribution is usually patchy. The relationship between CAA and AD is poorly understood; however, low positive correlations between the severity of both CAA and AD pathology have been observed. CAA is a frequent cause of (warfarin-associated) intracerebral hemorrhage, and the diagnosis of probable CAA-related hemorrhage can be made during life with high accuracy. Both APOE-epsilon4 and APOE-epsilon2 are risk factors for CAA, while only APOE-epsilon2 increases the risk for hemorrhage in CAA. Although the role of CAA as an independent risk factor for cognitive decline is unclear, severe CAA is likely to lower the threshold for clinically overt dementia in neurodegenerative diseases. As for the origin of Abeta in CAA, it may be both produced by smooth muscle cells (vessel wall) and derived from neurons in the course of perivascular drainage.

Cerebral amyloid angiopathy and thrombolysis-related intracerebral haemorrhage

Intracerebral haemorrhage is a complication of thrombolytic therapy for acute myocardial infarction, pulmonary embolism, and ischaemic stroke. There is increasing evidence that cerebral amyloid angiopathy (CAA), which itself can cause haemorrhage (CAAH), may be a risk factor for thrombolysis-related intracerebral haemorrhage. CAAH and thrombolysis-related intracerebral haemorrhage share some clinical features, such as predisposition to lobar or superficial regions of the brain, multiple haemorrhages, increasing frequency with age, and an association with dementia. In vitro work showed that accumulation of amyloid-beta peptide causes degeneration of cells in the walls of blood vessels, affects vasoactivity, and improves proteolytic mechanisms, such as fibrinolysis, anticoagulation, and degradation of the extracellular matrix. In a mouse model of CAA there is a low haemorrhagic threshold after thrombolytic therapy compared with that in wild-type mice. To date only a small number of anecdotal clinicopathological relations have been reported; neuroimaging advances and further study of the frequency and role of CAA in patients with thrombolysis-related intracerebral haemorrhage are required.

The diagnostic relevance of cerebral amyloid angiopathy in the setting of forensic pathology - a report of two cases and review of the literature

The neuropathological features seen in two cases with cerebral amyloid angiopathy (CAA) are presented. An 85-year-old woman was found comatose at home and died on the way to the hospital. The cause of death was an intracerebral hemorrhage (ICH) in the right parietal lobe. A 93-year-old woman with a history of traumatic subarachnoid hemorrhage was operated on for a chronic subdural hematoma. Intraoperatively, she developed severe ICH and died. The cause of death was an ICH in the parieto-occipital lobe. The morphology of the vessels was studied on differently stained sections and the neuropathological findings of the surrounding brain tissue were investigated. The affected vessels showed the characteristic alterations seen in CAA and included vascular amyloid deposition, fibrinoid necrosis, double-barrel lumen, splitting of the internal elastic lamina, defects of the vessel wall, and microaneurysms. Visualization of beta-amyloid protein was performed by histological and immunohistochemical methods. The immunohistochemistry for beta-amyloid was more sensitive and yielded better results compared with Congo red. In cases of ICH, CAA has to be considered in the differential diagnosis. Besides the use of Congo red stain, the application of beta-amyloid immunohistochemistry is requested to reliably make the diagnosis of CAA. Additional staining with a modified silver impregnation technique (AgNOR) is useful to detect associated neurodegenerative changes.

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Cerebral amyloid angiopathy: an overview

Cerebral amyloid angiopathy (CAA) is characterized by amyloid deposition in cortical and leptomeningeal vessels. Several cerebrovascular amyloid proteins (amyloid beta-protein (Abeta), cystatin C (ACys), prion protein (AScr), transthyretin (ATTR), gelsolin (AGel), and ABri (or A-WD)) have been identified, leading to the classification of several types of CAA. Sporadic CAA of Abeta type is commonly found in elderly individuals and patients with Alzheimer's disease. Cerebral amyloid angiopathy is an important cause of cerebrovascular disorders including lobar cerebral hemorrhage, leukoencephalopathy, and small cortical hemorrhage and infarction. We review the clinicopathological and molecular aspects of CAA and discuss the pathogenesis of CAA with future perspectives.

Amyloid angiopathy-related cerebellar hemorrhage

BACKGROUND

The posterior fossa localization of amyloid angiopathy-related hemorrhage is very unusual. Less than 10 cases have been previously reported. Surgical management of amyloid angiopathy-related hemorrhage is the subject of controversy.

RESULTS

Typical aspects of amyloid angiopathy were found within the surgically removed biopsies of 71-year-old nonhypertensive, nondemented woman suffering cerebellar hemorrhage.

CONCLUSIONS

Amyloid angiopathy-related hemorrhage could occur in the cerebellum, and diagnosis might be suspected when no past history of mental deterioration and/or arterial hypertension are present and when angiography rules out vascular malformation. Surgical management seems to have the same restricted indications as in other brain areas.

Surgical experience with massive lobar haemorrhage caused by cerebral amyloid angiopathy

Nineteen patients with massive lobar haemorrhage without angiographic lesions received direct or stereotactic surgery, and biopsy specimens were examined histologically. Ten patients (53%) were found to have vessels positive for Congo-red staining, and demonstrating amyloid angiopathy. In the patients with amyloid angiopathy, CT scan and surgical findings were investigated. Subarachnoid haemorrhage (9/10), irregularly shaped haematoma (9/10) and fluid-blood density level in the haematoma cavity (7/10) were frequently found on CT scan. The characteristic surgical findings in patients treated by direct surgery were subarachnoid haemorrhage adjacent to intracerebral haematoma (8/8) and the existence of a tangle of vessels in the haematoma cavity (4/8). Evacuation of haematomas was relatively easy, and difficulty of haemostasis was not encountered during surgery.