1
|
Schiavolin S, Camarda G, Mazzucchelli A, Mariniello A, Marinoni G, Storti B, Canavero I, Bersano A, Leonardi M. Cognitive and psychological characteristics in patients with Cerebral Amyloid Angiopathy: a literature review. Neurol Sci 2024; 45:3031-3049. [PMID: 38388894 DOI: 10.1007/s10072-024-07399-7] [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] [Received: 09/11/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024]
Abstract
AIM To review the current data on cognitive and psychological characteristics of patients with CAA and on the instruments used for their evaluation. METHODS A systematic search was performed in Embase, Scopus and PubMed with terms related to "cerebral amyloid angiopathy", "neuropsychological measures" and "patient-reported outcome measures" from January 2001 to December 2021. RESULTS Out of 2851 records, 18 articles were selected. The cognitive evaluation was present in all of which, while the psychological one only in five articles. The MMSE (Mini Mental State Examination), TMT (Trail Making Test), fluency test, verbal learning test, digit span, digit symbol and Rey figure tests were the most used cognitive tests, while executive function, memory, processing speed, visuospatial function, attention and language were the most frequent impaired cognitive functions. Depression was the most considered psychological factor usually measured with BDI (Beck Depression Inventory) and GDS (Geriatric Depression Scale). CONCLUSIONS The results of this study might be used in clinical practice as a guide to choose cognitive and psychological instruments and integrate them in the clinical evaluation. The results might also be used in the research field for studies investigating the impact of cognitive and psychological variables on the disease course and for consensus studies aimed at define a standardized evaluation of these aspects.
Collapse
Affiliation(s)
- Silvia Schiavolin
- SC Neurologia, Salute Pubblica E Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Giorgia Camarda
- SC Neurologia, Salute Pubblica E Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy.
| | - Alessia Mazzucchelli
- SC Neurologia, Salute Pubblica E Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Arianna Mariniello
- SC Neurologia, Salute Pubblica E Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Giulia Marinoni
- SC Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Benedetta Storti
- SC Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Canavero
- SC Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Anna Bersano
- SC Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Matilde Leonardi
- SC Neurologia, Salute Pubblica E Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133, Milan, Italy
| |
Collapse
|
2
|
Fusco L, Palamà Z, Scarà A, Borrelli A, Robles AG, De Masi De Luca G, Romano S, Sciarra L. Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine. World J Cardiol 2024; 16:231-239. [PMID: 38817646 PMCID: PMC11135332 DOI: 10.4330/wjc.v16.i5.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/29/2024] [Accepted: 04/09/2024] [Indexed: 05/23/2024] Open
Abstract
The use of anticoagulation therapy could prove to be controversial when trying to balance ischemic stroke and intracranial bleeding risks in patients with concurrent cerebral amyloid angiopathy (CAA) and atrial fibrillation (AF). In fact, CAA is an age-related cerebral vasculopathy that predisposes patients to intracerebral hemorrhage. Nevertheless, many AF patients require oral systemic dose-adjusted warfarin, direct oral anticoagulants (such as factor Xa inhibitors) or direct thrombin inhibitors to control often associated with cardioembolic stroke risk. The prevalence of both CAA and AF is expected to rise, due to the aging of the population. This clinical dilemma is becoming increasingly common. In patients with coexisting AF and CAA, the risks/benefits profile of anticoagulant therapy must be assessed for each patient individually due to the lack of a clear-cut consensus with regard to its risks in scientific literature. This review aims to provide an overview of the management of patients with concomitant AF and CAA and proposes the implementation of a risk-based decision-making algorithm.
Collapse
Affiliation(s)
- Liuba Fusco
- Department of Cardiology, University Hospital of Northamptonshire, Northampton NN1 5BD, United Kingdom
| | - Zefferino Palamà
- Department of Cardiology, Casa di Cura Villa Verde, Taranto 70124, Italy
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy.
| | - Antonio Scarà
- Department of Cardiology, GVM Care and Research, San Carlo di Nancy Hospital, Rome 00100, Italy
| | - Alessio Borrelli
- Department of Cardiology, GVM Care and Research, San Carlo di Nancy Hospital, Rome 00100, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Gabriele De Masi De Luca
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| |
Collapse
|
3
|
Nagaraja N, Ballur Narayana Reddy V. Prevalence of Concomitant Neurological Disorders and Long-Term Outcome of Patients Hospitalized for Intracerebral Hemorrhage with Versus without Cerebral Amyloid Angiopathy. Neurocrit Care 2024; 40:486-494. [PMID: 37258986 DOI: 10.1007/s12028-023-01753-x] [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] [Received: 10/18/2022] [Accepted: 05/10/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Patients with intracerebral hemorrhage (ICH) related to cerebral amyloid angiopathy (CAA) are at increased risk of developing epilepsy and cognitive disorders such as Alzheimer's disease (AD), mild cognitive impairment (MCI), and vascular dementia. In a retrospective cohort observation study of patients hospitalized for ICH with CAA versus ICH without CAA, we evaluated the prevalence of neurological comorbidities at admission and the risk of new diagnosis of epilepsy, relevant cognitive disorders, and mortality at 1 year. METHODS In the TriNetX health research network, adult patients aged ≥ 55 years hospitalized with a diagnosis of ICH were stratified based on presence or absence of concomitant CAA diagnosis. Demographics and medical comorbidities were compared by using χ2 test and Student's t-test. After 1:1 propensity score matching, 1-year survival was assessed with Kaplan-Meier curves. The 1-year risk of new diagnosis of epilepsy, AD, MCI, vascular dementia, and dementia unspecified was assessed with Cox proportional hazards estimate. RESULTS The study included a total of 1757 patients with ICH and CAA and 53,364 patients with ICH without CAA. Patients with CAA were older compared with those without CAA (74.1 ± 7.5 vs. 69.8 ± 8.8 years, p ≤ 0.001). Compared with ICH without CAA, patients with ICH and CAA had higher baseline prevalence of cerebral infarction (30% vs. 20%), nontraumatic ICH (36% vs. 7%), nontraumatic subarachnoid hemorrhage (14% vs. 5%), epilepsy (11% vs. 6%), and AD (5% vs. 2%) with significance at p < 0.001. After propensity score matching, a total of 1746 patients were included in both cohorts. In the matched cohorts, compared with patients with ICH without CAA, patients with ICH and CAA had lower 1-year all-cause mortality (479 [27%] vs. 563 [32%]; hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.71-0.90) and higher risk of new diagnosis of epilepsy (280 [18%] vs. 167 [11%]; HR 1.70; 95% CI 1.40-2.06), AD (101 [6%] vs. 38 [2%]; HR 2.62; 95% CI 1.80-3.80), MCI (85 [5%] vs. 35 [2%]; HR 2.39; 95% CI 1.61-3.54), vascular dementia (117 [7%] vs. 60 [4%]; HR 1.92; 95% CI 1.41-2.62), and dementia unspecified (245 [16%] vs. 150 [9%]; HR 1.70; 95% CI 1.39-2.08). CONCLUSIONS Among patients admitted for ICH, patients with CAA have lower mortality but have 2-3 times more risk of diagnosis of epilepsy and dementia at 1 year, compared with those without CAA.
Collapse
Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, Milton S. Hershey Medical Center, Penn State College of Medicine, 30 Hope Drive EC037, Hershey, PA, 17033, USA.
| | - Varalakshmi Ballur Narayana Reddy
- Department of Neurology, Milton S. Hershey Medical Center, Penn State College of Medicine, 30 Hope Drive EC037, Hershey, PA, 17033, USA
| |
Collapse
|
4
|
Wheeler KV, Irimia A, Braskie MN. Using Neuroimaging to Study Cerebral Amyloid Angiopathy and Its Relationship to Alzheimer's Disease. J Alzheimers Dis 2024; 97:1479-1502. [PMID: 38306032 DOI: 10.3233/jad-230553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Cerebral amyloid angiopathy (CAA) is characterized by amyloid-β aggregation in the media and adventitia of the leptomeningeal and cortical blood vessels. CAA is one of the strongest vascular contributors to Alzheimer's disease (AD). It frequently co-occurs in AD patients, but the relationship between CAA and AD is incompletely understood. CAA may drive AD risk through damage to the neurovascular unit and accelerate parenchymal amyloid and tau deposition. Conversely, early AD may also drive CAA through cerebrovascular remodeling that impairs blood vessels from clearing amyloid-β. Sole reliance on autopsy examination to study CAA limits researchers' ability to investigate CAA's natural disease course and the effect of CAA on cognitive decline. Neuroimaging allows for in vivo assessment of brain function and structure and can be leveraged to investigate CAA staging and explore its associations with AD. In this review, we will discuss neuroimaging modalities that can be used to investigate markers associated with CAA that may impact AD vulnerability including hemorrhages and microbleeds, blood-brain barrier permeability disruption, reduced cerebral blood flow, amyloid and tau accumulation, white matter tract disruption, reduced cerebrovascular reactivity, and lowered brain glucose metabolism. We present possible areas for research inquiry to advance biomarker discovery and improve diagnostics.
Collapse
Affiliation(s)
- Koral V Wheeler
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Marina Del Rey, CA, USA
| | - Andrei Irimia
- Ethel Percy Andrus Gerontology Center, USC Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
- Department of Biomedical Engineering, Corwin D. Denney Research Center, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Meredith N Braskie
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Marina Del Rey, CA, USA
| |
Collapse
|
5
|
Yamada SM, Tomita Y, Iwamoto N, Takeda R, Nakane M, Aso T, Takahashi M. Subcortical hemorrhage caused by cerebral amyloid angiopathy compared with hypertensive hemorrhage. Clin Neurol Neurosurg 2024; 236:108076. [PMID: 38128259 DOI: 10.1016/j.clineuro.2023.108076] [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] [Received: 09/21/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Most published reports on lobular hemorrhage in cerebral amyloid angiopathy (CAA) include patients diagnosed only by imaging studies. This study analyzed patients with subcortical hemorrhage histologically diagnosed as CAA or non-CAA (hypertensive). METHODS This is a retrospective study analyzing data from 100 craniotomy cases. Tissue of hematoma cavity wall was collected for histological investigation in hematoma removal by surgery in patients with subcortical hemorrhage. Statistical analyses of blood pressure, hematoma location and volume, outcome, and mortality was performed in CAA and non-CAA groups. RESULTS There were 47 CAA and 53 non-CAA cases, and average age was significantly older in the CAA group (p < 0.01). Blood pressure was significantly lower (p < 0.01) but hematoma volume was significantly greater (p < 0.05) in the CAA group. Rebleeding occurred in two CAA cases and one non-CAA case, but no re-operations were required. Average score of modified Rankin Scale, which is used to measure the degree of disability in patients who have had a stroke, at three months after surgery was not significantly different between the two groups (CAA: 3.94 ± 1.28, non-CAA: 3.58 ± 1.50). There were seven deaths in the CAA and six in the non-CAA group, and intraventricular hemorrhage highly complicated in the death cases in both groups. In the CAA group, average age of the fatal cases was significantly older than that of the surviving cases (p < 0.05) and six cases demonstrated dementia before onset of hemorrhage. CONCLUSIONS Surgical removal of a subcortical hemorrhage caused by CAA is not contraindicated. However, age > 80 years, complication with intraventricular hemorrhage, hematoma volume ≥ 50 ml, and dementia before onset of hemorrhage contribute to high mortality, and craniotomy should be carefully considered for such patients. A limitation of this study is that comparison between CAA and non-CAA groups was performed in the patients with only surgically indicated ICH, and does not evaluate entire ICH cases with CAA. However, this study appropriately compared pathologically diagnosed CAA and non-CAA in patients with moderate to severe lobular ICH with surgical indications.
Collapse
Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan.
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Naotaka Iwamoto
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Ririko Takeda
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Tatsuya Aso
- Department of Diagnostic Pathology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Mikiko Takahashi
- Department of Diagnostic Pathology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| |
Collapse
|
6
|
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.
Collapse
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;
| |
Collapse
|
7
|
Banerjee G, Collinge J, Fox NC, Lashley T, Mead S, Schott JM, Werring DJ, Ryan NS. Clinical considerations in early-onset cerebral amyloid angiopathy. Brain 2023; 146:3991-4014. [PMID: 37280119 PMCID: PMC10545523 DOI: 10.1093/brain/awad193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 04/16/2023] [Accepted: 05/01/2023] [Indexed: 06/08/2023] Open
Abstract
Cerebral amyloid angiopathy (CAA) is an important cerebral small vessel disease associated with brain haemorrhage and cognitive change. The commonest form, sporadic amyloid-β CAA, usually affects people in mid- to later life. However, early-onset forms, though uncommon, are increasingly recognized and may result from genetic or iatrogenic causes that warrant specific and focused investigation and management. In this review, we firstly describe the causes of early-onset CAA, including monogenic causes of amyloid-β CAA (APP missense mutations and copy number variants; mutations of PSEN1 and PSEN2) and non-amyloid-β CAA (associated with ITM2B, CST3, GSN, PRNP and TTR mutations), and other unusual sporadic and acquired causes including the newly-recognized iatrogenic subtype. We then provide a structured approach for investigating early-onset CAA, and highlight important management considerations. Improving awareness of these unusual forms of CAA amongst healthcare professionals is essential for facilitating their prompt diagnosis, and an understanding of their underlying pathophysiology may have implications for more common, late-onset, forms of the disease.
Collapse
Affiliation(s)
- Gargi Banerjee
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - John Collinge
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - Nick C Fox
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
| | - Tammaryn Lashley
- The Queen Square Brain Bank for Neurological Disorders, Department of Clinical and Movement Disorders, UCL Queen Square Institute of Neurology, London, W1 1PJ, UK
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Simon Mead
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Natalie S Ryan
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
| |
Collapse
|
8
|
Koemans EA, Chhatwal JP, van Veluw SJ, van Etten ES, van Osch MJP, van Walderveen MAA, Sohrabi HR, Kozberg MG, Shirzadi Z, Terwindt GM, van Buchem MA, Smith EE, Werring DJ, Martins RN, Wermer MJH, Greenberg SM. Progression of cerebral amyloid angiopathy: a pathophysiological framework. Lancet Neurol 2023; 22:632-642. [PMID: 37236210 DOI: 10.1016/s1474-4422(23)00114-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 02/21/2023] [Accepted: 03/14/2023] [Indexed: 05/28/2023]
Abstract
Cerebral amyloid angiopathy, which is defined by cerebrovascular deposition of amyloid β, is a common age-related small vessel pathology associated with intracerebral haemorrhage and cognitive impairment. Based on complementary lines of evidence from in vivo studies of individuals with hereditary, sporadic, and iatrogenic forms of cerebral amyloid angiopathy, histopathological analyses of affected brains, and experimental studies in transgenic mouse models, we present a framework and timeline for the progression of cerebral amyloid angiopathy from subclinical pathology to the clinical manifestation of the disease. Key stages that appear to evolve sequentially over two to three decades are (stage one) initial vascular amyloid deposition, (stage two) alteration of cerebrovascular physiology, (stage three) non-haemorrhagic brain injury, and (stage four) appearance of haemorrhagic brain lesions. This timeline of stages and the mechanistic processes that link them have substantial implications for identifying disease-modifying interventions for cerebral amyloid angiopathy and potentially for other cerebral small vessel diseases.
Collapse
Affiliation(s)
- Emma A Koemans
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jasmeer P Chhatwal
- Department of Neurology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Susanne J van Veluw
- Department of Neurology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Ellis S van Etten
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Matthias J P van Osch
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hamid R Sohrabi
- Centre for Healthy Ageing, Health Future Institute, Murdoch University, Perth, WA, Australia; Department of Biomedical Sciences, Macquarie University, North Ryde, NSW, Australia
| | - Mariel G Kozberg
- Department of Neurology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Zahra Shirzadi
- Department of Neurology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Gisela M Terwindt
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark A van Buchem
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London, UK
| | - Ralph N Martins
- Centre for Healthy Ageing, Health Future Institute, Murdoch University, Perth, WA, Australia; Department of Biomedical Sciences, Macquarie University, North Ryde, NSW, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Marieke J H Wermer
- Department of Neurology and Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Steven M Greenberg
- Department of Neurology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
9
|
Voigt S, Koemans EA, Rasing I, van Etten ES, Terwindt GM, Baas F, Kaushik K, van Es ACGM, van Buchem MA, van Osch MJP, van Walderveen MAA, Klijn CJM, Verbeek MM, van der Weerd L, Wermer MJH. Minocycline for sporadic and hereditary cerebral amyloid angiopathy (BATMAN): study protocol for a placebo-controlled randomized double-blind trial. Trials 2023; 24:378. [PMID: 37277877 DOI: 10.1186/s13063-023-07371-4] [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: 03/06/2023] [Accepted: 05/11/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is a disease caused by the accumulation of the amyloid-beta protein and is a major cause of intracerebral hemorrhage (ICH) and vascular dementia in the elderly. The presence of the amyloid-beta protein in the vessel wall may induce a chronic state of cerebral inflammation by activating astrocytes, microglia, and pro-inflammatory substances. Minocycline, an antibiotic of the tetracycline family, is known to modulate inflammation, gelatinase activity, and angiogenesis. These processes are suggested to be key mechanisms in CAA pathology. Our aim is to show the target engagement of minocycline and investigate in a double-blind placebo-controlled randomized clinical trial whether treatment with minocycline for 3 months can decrease markers of neuroinflammation and of the gelatinase pathway in cerebrospinal fluid (CSF) in CAA patients. METHODS The BATMAN study population consists of 60 persons: 30 persons with hereditary Dutch type CAA (D-CAA) and 30 persons with sporadic CAA. They will be randomized for either placebo or minocycline (15 sporadic CAA/15 D-CAA minocycline, 15 sporadic CAA/15 D-CAA placebo). At t = 0 and t = 3 months, we will collect CSF and blood samples, perform a 7-T MRI, and collect demographic characteristics. DISCUSSION The results of this proof-of-principle study will be used to assess the potential of target engagement of minocycline for CAA. Therefore, our primary outcome measures are markers of neuroinflammation (IL-6, MCP-1, and IBA-1) and of the gelatinase pathway (MMP2/9 and VEGF) in CSF. Secondly, we will look at the progression of hemorrhagic markers on 7-T MRI before and after treatment and investigate serum biomarkers. TRIAL REGISTRATION ClinicalTrials.gov NCT05680389. Registered on January 11, 2023.
Collapse
Affiliation(s)
- S Voigt
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - E A Koemans
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - I Rasing
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E S van Etten
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - G M Terwindt
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - F Baas
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - K Kaushik
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - A C G M van Es
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M A van Buchem
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M J P van Osch
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M A A van Walderveen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - C J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M M Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L van der Weerd
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M J H Wermer
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| |
Collapse
|
10
|
Greenberg SM, Charidimou A. Seed to Bleed: Iatrogenic Cerebral Amyloid Angiopathy. Stroke 2023; 54:1224-1226. [PMID: 37035915 PMCID: PMC10473030 DOI: 10.1161/strokeaha.123.042583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Affiliation(s)
- Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Andreas Charidimou
- Department of Neurology, Boston University Medical Center and Boston University School of Medicine, MA (A.C.)
| |
Collapse
|
11
|
Kaushik K, van Etten ES, Siegerink B, Kappelle LJ, Lemstra AW, Schreuder FH, Klijn CJ, Peul WC, Terwindt GM, van Walderveen MA, Wermer MJ. Iatrogenic Cerebral Amyloid Angiopathy Post Neurosurgery: Frequency, Clinical Profile, Radiological Features, and Outcome. Stroke 2023; 54:1214-1223. [PMID: 37035916 PMCID: PMC10121246 DOI: 10.1161/strokeaha.122.041690] [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] [Received: 10/18/2022] [Revised: 03/01/2023] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Prion-like transmission of amyloid-ß through cadaveric dura, decades after neurosurgical procedures, has been hypothesized as an iatrogenic cause of cerebral amyloid angiopathy (CAA). We investigated new and previously described patients to assess the clinical profile, radiological features, and outcome of this presumed iatrogenic CAA-subtype (iCAA). METHODS Patients were collected from our prospective lobar hemorrhage and CAA database (n=251) with patients presenting to our hospital between 2008 and 2022. In addition, we identified patients with iCAA from 2 other Dutch CAA-expertise hospitals and performed a systematic literature-search for previously described patients. We classified patients according to the previously proposed diagnostic criteria for iCAA, assessed clinical and radiological disease features, and calculated intracerebral hemorrhage (ICH)-recurrence rates. We evaluated the spatial colocalization of cadaveric dura placement and CAA-associated magnetic resonance imaging markers. RESULTS We included 49 patients (74% men, mean age 43 years [range, 27-84]); 15 from our database (6% [95% CI, 3%-10%]; 45% of patients <55 years), 3 from the 2 other CAA-expertise hospitals, and 31 from the literature. We classified 43% (n=21; 1 newly identified patient) as probable and 57% (n=28) as possible iCAA. Patients presented with lobar ICH (57%), transient focal neurological episodes (12%), or seizures (8%). ICH-recurrence rate in the new patients (16/100 person-years [95% CI, 7-32], median follow-up 18 months) was lower than in the previously described patients (77/100 person-years [95% CI, 59-99], median follow-up 18 months). One patient had a 10 year interlude without ICH-recurrence. We identified no clear spatial relationship between dura placement and CAA-associated magnetic resonance imaging markers. During follow-up (median, 18 months), 20% of the patients developed transient focal neurological episodes and 20% cognitively declined. CONCLUSIONS iCAA seems common in patients presenting with nonhereditary CAA under the age of 55. Clinical and radiological features are comparable with sCAA. After diagnosis, multiple ICH-recurrences but also long symptom-free intervals can occur. Harmonized registries are necessary to identify and understand this potentially underrecognized CAA-subtype.
Collapse
Affiliation(s)
- Kanishk Kaushik
- Department of Neurology (K.K., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Ellis S. van Etten
- Department of Neurology (K.K., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Bob Siegerink
- Department of Clinical Epidemiology (B.S.), Leiden University Medical Center, the Netherlands
| | - L. Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, the Netherlands (L.J.K.)
| | - Afina W. Lemstra
- Department of Neurology, Alzheimer center Amsterdam, Amsterdam University Medical Center, the Netherlands (A.W.L.)
| | - Floris H.B.M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Wilco C. Peul
- University Neurosurgical Center Holland, LUMC|HMC|HAGA Leiden & The Hague, the Netherlands (W.C.P.)
| | - Gisela M. Terwindt
- Department of Neurology (K.K., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | | | - Marieke J.H. Wermer
- Department of Neurology (K.K., E.S.v.E., G.M.T., M.J.H.W.), Leiden University Medical Center, the Netherlands
| |
Collapse
|
12
|
Koemans EA, van Walderveen MAA, Voigt S, Rasing I, van Harten TW, J A van Os H, van der Weerd N, Terwindt GM, van Osch MJP, van Veluw SJ, Freeze WM, Wermer MJH. Subarachnoid CSF hyperintensities at 7 tesla FLAIR MRI: A novel marker in cerebral amyloid angiopathy. Neuroimage Clin 2023; 38:103386. [PMID: 36989852 PMCID: PMC10074985 DOI: 10.1016/j.nicl.2023.103386] [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] [Received: 12/27/2022] [Revised: 02/25/2023] [Accepted: 03/24/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND We observed subarachnoid cerebrospinal fluid (CSF) hyperintensities at non-contrast 7-tesla (T) fluid-attenuated inversion recovery (FLAIR) MRI, frequently topographically associated with cortical superficial siderosis (cSS), in participants with cerebral amyloid angiopathy (CAA). To systemically evaluate these CSF hyperintensities we investigated their frequency and anatomical and temporal relationship with cSS on 7T and 3T MRI in hereditary Dutch-type CAA (D-CAA), sporadic CAA (sCAA), and non-CAA controls. METHODS CAA participants were included from two prospective natural history studies and non-CAA controls from a 7T study in healthy females and females with ischemic stroke. CSF hyperintensities were scored by two independent observers. RESULTS We included 38 sCAA participants (mean age 72y), 50 D-CAA participants (mean age 50y) and 44 non-CAA controls (mean age 53y, 15 with stroke). In total 27/38 (71 %, 95 %CI 56-84) sCAA and 23/50 (46 %, 95 %CI 33-60) D-CAA participants had subarachnoid CSF hyperintensities at baseline 7T. Most (96 %) of those had cSS, in 54 % there was complete topographical overlap with cSS. The remaining 46 % had ≥1 sulcus with CSF hyperintensities without co-localizing cSS. None of the healthy controls and 2/15 (13 %, 95 %CI 2-41, 100 % cSS overlap) of the stroke controls had CSF hyperintensities. In 85 % of the CAA participants CSF hyperintensities could retrospectively be identified at 3T. Of the 35 CAA participants with follow-up 7T after two years, 17/35 (49 %) showed increase and 6/35 (17 %) decrease of regional CSF hyperintensities. In 2/11 (18 %) of participants with follow-up who had baseline CSF hyperintensities without overlapping cSS, new cSS developed at those locations. CONCLUSIONS Subarachnoid CSF hyperintensities at 7T FLAIR MRI occur frequently in CAA and are associated with cSS, although without complete overlap. We hypothesize that the phenomenon could be a sign of subtle plasma protein or blood product leakage into the CSF, resulting in CSF T1-shortening.
Collapse
Affiliation(s)
- Emma A Koemans
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands.
| | | | - Sabine Voigt
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands; Leiden University Medical Center, Department of Radiology, Leiden, The Netherlands
| | - Ingeborg Rasing
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands
| | - Thijs W van Harten
- Leiden University Medical Center, Department of Radiology, Leiden, The Netherlands
| | - Hine J A van Os
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands; Leiden University Medical Center, Department of Public Health, Leiden, The Netherlands
| | | | - Gisela M Terwindt
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands
| | | | - Susanne J van Veluw
- Leiden University Medical Center, Department of Radiology, Leiden, The Netherlands; Massachusetts General Hospital, Harvard Medical School, J. Philip Kistler Stroke Research Center, Boston, MA, USA; Massachusetts General Hospital, MassGeneral Institute for Neurodegenerative Disease, Charlestown, MA, USA
| | - Whitney M Freeze
- Leiden University Medical Center, Department of Radiology, Leiden, The Netherlands
| | - Marieke J H Wermer
- Leiden University Medical Center, Department of Neurology, Leiden, The Netherlands
| |
Collapse
|
13
|
Koemans EA, Castello JP, Rasing I, Abramson JR, Voigt S, Perosa V, van Harten TW, van Zwet EW, Terwindt GM, Gurol ME, Rosand J, Greenberg SM, van Walderveen MA, Biffi A, Viswanathan A, Wermer MJ. Sex Differences in Onset and Progression of Cerebral Amyloid Angiopathy. Stroke 2023; 54:306-314. [PMID: 36689586 PMCID: PMC9855754 DOI: 10.1161/strokeaha.122.040823] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cerebral Amyloid Angiopathy (CAA) disease course is highly variable even in hereditary forms. Sex may be a possible modifying factor. We investigated biological sex differences in clinical disease course and magnetic resonance imaging-markers in sporadic (sCAA) and Dutch-type hereditary CAA (D-CAA). METHODS Patients with D-CAA and sCAA were included from hospital and research databases of the Leiden University Medical Center (2012-2020) and Massachusetts General Hospital (1994-2012). Key outcomes were: sex differences in symptomatic intracerebral hemorrhage (sICH) onset, recurrence and survival (analyzed using Kaplan Meier survival and regression analyses), and sex differences in magnetic resonance imaging-markers in D-CAA (explored using scatterplots), and in sCAA (investigated using regression analysis). RESULTS We included 136 patients with D-CAA (mean age 57 years, 56% women, 64% with previous sICH) and 370 patients with sCAA (mean age 76 years, 51% women, all with previous sICH). Men and women with D-CAA did not differ for sICH onset (median age 54 in men and 56 in women [P=0.13]). Men with D-CAA had a slightly higher number of sICH compared with women (median 2 versus 1; adjusted RR, 1.5 [95% CI, 1.1-1.9]) and a shorter interval between the first and second sICH (median 1.8 years for men and 3.1 years for women, P=0.02). Men with sCAA had their first sICH at an earlier age (median 75 versus 78 years, respectively, P=0.003) and more lobar microbleeds (median 1 versus 0, P=0.022) compared with women with sCAA. No substantial differences were found in the other magnetic resonance imaging markers. Survival after first sICH was comparable between sexes for D-CAA (P=0.12) and sCAA (P=0.23). CONCLUSIONS Men with CAA seem to have an earlier onset (sCAA) and more hemorrhagic disease course (sCAA and D-CAA) compared with women. Future studies are necessary to confirm these findings and determine the underlying role of sex-related factors.
Collapse
Affiliation(s)
- Emma A. Koemans
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - Juan Pablo Castello
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.P.C.)
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - Jessica R. Abramson
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Sabine Voigt
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
- Department of Radiology, Leiden University Medical Center, the Netherlands (S.V., T.W.v.H., M.A.A.v.W.)
| | - Valentina Perosa
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany (V.P.)
| | - Thijs W. van Harten
- Department of Radiology, Leiden University Medical Center, the Netherlands (S.V., T.W.v.H., M.A.A.v.W.)
| | - Erik W. van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands (E.W.v.Z.)
| | - Gisela M. Terwindt
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| | - M. Edip Gurol
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Steven M. Greenberg
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | | | - Alessandro Biffi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., J.R., A.B.)
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Anand Viswanathan
- Department of Neurology, J Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.C., J.R.A., V.P., M.E.G., J.R., S.M.G., A.B., A.V.)
| | - Marieke J.H. Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands (E.A.K., I.R., S.V., G.M.T., M.J.H.W.)
| |
Collapse
|
14
|
Shirzadi Z, Yau WYW, Schultz SA, Schultz AP, Scott MR, Goubran M, Mojiri-Forooshani P, Joseph-Mathurin N, Kantarci K, Preboske G, Wermer MJH, Jack C, Benzinger T, Taddei K, Sohrabi HR, Sperling RA, Johnson KA, Bateman RJ, Martins RN, Greenberg SM, Chhatwal JP. Progressive White Matter Injury in Preclinical Dutch Cerebral Amyloid Angiopathy. Ann Neurol 2022; 92:358-363. [PMID: 35670654 PMCID: PMC9391284 DOI: 10.1002/ana.26429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 11/07/2022]
Abstract
Autosomal-dominant, Dutch-type cerebral amyloid angiopathy (D-CAA) offers a unique opportunity to develop biomarkers for pre-symptomatic cerebral amyloid angiopathy (CAA). We hypothesized that neuroimaging measures of white matter injury would be present and progressive in D-CAA prior to hemorrhagic lesions or symptomatic hemorrhage. In a longitudinal cohort of D-CAA carriers and non-carriers, we observed divergence of white matter injury measures between D-CAA carriers and non-carriers prior to the appearance of cerebral microbleeds and >14 years before the average age of first symptomatic hemorrhage. These results indicate that white matter disruption measures may be valuable cross-sectional and longitudinal biomarkers of D-CAA progression. ANN NEUROL 2022;92:358-363.
Collapse
Affiliation(s)
- Zahra Shirzadi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Wai-Ying W Yau
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Stephanie A Schultz
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aaron P Schultz
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matthew R Scott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Maged Goubran
- Physical Sciences Platform and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Parisa Mojiri-Forooshani
- Physical Sciences Platform and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Nelly Joseph-Mathurin
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | | | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Tammie Benzinger
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Kevin Taddei
- Centre of Excellence for Alzheimer's Disease Research and Care, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Hamid R Sohrabi
- Centre for Healthy Ageing, Health Future Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Reisa A Sperling
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith A Johnson
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Randall J Bateman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Ralph N Martins
- Centre of Excellence for Alzheimer's Disease Research and Care, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jasmeer P Chhatwal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
15
|
Marazuela P, Paez-Montserrat B, Bonaterra-Pastra A, Solé M, Hernández-Guillamon M. Impact of Cerebral Amyloid Angiopathy in Two Transgenic Mouse Models of Cerebral β-Amyloidosis: A Neuropathological Study. Int J Mol Sci 2022; 23:ijms23094972. [PMID: 35563362 PMCID: PMC9103818 DOI: 10.3390/ijms23094972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
The pathological accumulation of parenchymal and vascular amyloid-beta (Aβ) are the main hallmarks of Alzheimer’s disease (AD) and Cerebral Amyloid Angiopathy (CAA), respectively. Emerging evidence raises an important contribution of vascular dysfunction in AD pathology that could partially explain the failure of anti-Aβ therapies in this field. Transgenic mice models of cerebral β-amyloidosis are essential to a better understanding of the mechanisms underlying amyloid accumulation in the cerebrovasculature and its interactions with neuritic plaque deposition. Here, our main objective was to evaluate the progression of both parenchymal and vascular deposition in APP23 and 5xFAD transgenic mice in relation to age and sex. We first showed a significant age-dependent accumulation of extracellular Aβ deposits in both transgenic models, with a greater increase in APP23 females. We confirmed that CAA pathology was more prominent in the APP23 mice, demonstrating a higher progression of Aβ-positive vessels with age, but not linked to sex, and detecting a pronounced burden of cerebral microbleeds (cMBs) by magnetic resonance imaging (MRI). In contrast, 5xFAD mice did not present CAA, as shown by the negligible Aβ presence in cerebral vessels and the occurrence of occasional cMBs comparable to WT mice. In conclusion, the APP23 mouse model is an interesting tool to study the overlap between vascular and parenchymal Aβ deposition and to evaluate future disease-modifying therapy before its translation to the clinic.
Collapse
|
16
|
Abdulrahman H, Smedinga M, Verbeek MM, Klijn CJM, Richard E, Perry M. Views on the Desirability of Diagnosing Sporadic Cerebral Amyloid Angiopathy with Biological Evidence. J Alzheimers Dis 2022; 87:807-816. [PMID: 35404283 PMCID: PMC9198748 DOI: 10.3233/jad-220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sporadic cerebral amyloid angiopathy (sCAA) research of the past decade has increasingly focused on developing biomarkers that allow for an earlier and more accurate sCAA-diagnosis. Considering that sCAA does not have treatment options available (yet), more fundamental questions concerning the desirability of using such early-sCAA biomarkers in clinical practice need to be addressed. OBJECTIVE In this qualitative interview study, we aim to explore the views of vascular neurologists on the purpose and possible consequences of an earlier and more accurate sCAA-diagnosis, using new biomarkers. METHODS Vascular neurologists from around the world were approached via email and interviewed via video call. Topics included views on current sCAA diagnostic practice, considerations on the use of new biomarkers, and expectations and hopes for the future. All interviews were transcribed ad verbatim using a transcription program (Otter.ai). Transcripts were analyzed using inductive content analysis. RESULTS We interviewed 14 vascular neurologists. Views regarding the desirability of new sCAA-biomarkers differed substantially between interviewees as to when and in whom these biomarkers could be of benefit in clinical practice. These differences were mainly reported with regards to prognosis, risk stratification, and biological precision, between general stroke neurologists and neurologists with specific sCAA-expertise. CONCLUSION Views on the use of sCAA-biomarkers in clinical practice differ substantially between vascular neurologists. There is particularly no consensus regarding when, and in whom sCAA biomarkers could be useful in clinical practice.
Collapse
Affiliation(s)
- Herrer Abdulrahman
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marthe Smedinga
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel M Verbeek
- Department of Laboratory Medicine, Radboud Alzheimer Centre, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Alzheimer Centre, Radboud University Medical Center, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Alzheimer Centre, Radboud University Medical Center, The Netherlands
| | - Marieke Perry
- Radboud Alzheimer Centre, Radboud University Medical Center, The Netherlands.,Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
17
|
van Dijk SE, van der Grond J, Lak J, van den Berg-Huysmans A, Labadie G, Terwindt GM, Wermer MJH, Gurol ME, van Buchem MA, Greenberg SM, van Rooden S. Longitudinal Progression of Magnetic Resonance Imaging Markers and Cognition in Dutch-Type Hereditary Cerebral Amyloid Angiopathy. Stroke 2022; 53:2006-2015. [PMID: 35360926 PMCID: PMC9126261 DOI: 10.1161/strokeaha.121.035826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hemorrhagic and ischemic magnetic resonance imaging lesions as well as the more recently described decrease in vasomotor reactivity have been suggested as possible biomarkers for cerebral amyloid angiopathy (CAA). Analyses of these markers have been primarily cross-sectional during the symptomatic phase of the disease, with little data on their longitudinal progression, particularly in the presymptomatic phase of the disease when it may be most responsive to treatment. We used the unique opportunity provided by studying Dutch-type hereditary cerebral amyloid angiopathy (D-CAA) to determine longitudinal progression of CAA biomarkers during the presymptomatic as well as the symptomatic phase of the disease.
Collapse
Affiliation(s)
- Suzanne E van Dijk
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Jeroen van der Grond
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Jessie Lak
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Annette van den Berg-Huysmans
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Gerda Labadie
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Gisela M Terwindt
- Department of Neurology,Leiden University Medical Center, Leiden, the Netherlands. (G.M.T., M.J.H.W.)
| | - Marieke J H Wermer
- Department of Neurology,Leiden University Medical Center, Leiden, the Netherlands. (G.M.T., M.J.H.W.)
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston (M.E.G., S.M.G.)
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston (M.E.G., S.M.G.)
| | - Sanneke van Rooden
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. (S.E.v.D., J.v.d.G., J.L., A.v.d.B-H, G.L., M.A.v.B., S.v.R)
| |
Collapse
|
18
|
A Case of Metastatic CNS Melanoma of Unknown Primary Presenting with Seizures. Case Rep Med 2022; 2022:3099750. [PMID: 35035488 PMCID: PMC8758325 DOI: 10.1155/2022/3099750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Seizures are a common occurrence. The goal of evaluating a seizure is to identify the etiology and to determine the likelihood of recurrence as well as guide management. We present a unique presentation of a 47-year-old female that presented with late onset seizures admitted due to status epilepticus. Brain magnetic resonance indicated diffuse supratentorial hemorrhagic lesions. Neurological workup including brain vessel imaging, CT chest, abdomen, and pelvis as well as CSF and serological workup for vasculitis failed to demonstrate the cause of her brain lesions. Ultimately, a brain biopsy showed metastatic melanoma of unknown primary origin.
Collapse
|
19
|
Biffi A. Main features of hereditary cerebral amyloid angiopathies: A systematic review. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2022; 3:100124. [PMID: 36324420 PMCID: PMC9616336 DOI: 10.1016/j.cccb.2022.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/19/2022] [Indexed: 12/04/2022]
Abstract
Cerebral Amyloid Angiopathy (CAA) is a major contributor to stroke risk, cognitive decline, as well as multiple neurobehavioral and neuropsychiatric disturbances. Most CAA cases are sporadic, but many hereditary forms exist and present as familial monogenic disorders with early-onset hemorrhagic stroke and dementia. Hereditary CAA is usually characterized by earlier age at onset and more severe course when compared to sporadic CAA. Most forms of hereditary CAA are caused by APP mutations, leading to accumulation of amyloid beta in vascular deposits within the small vessels of the central nervous system. Cognitive decline is a common manifestation of hereditary CAA, either due to recurrent hemorrhagic stroke events or as chronic progression of small vessel vasculopathy. Recent studies highlighted increased risk for behavioral and psychiatric disorders among individuals affect by sporadic CAA, thus warranting similarly focused future investigations for hereditary CAA.
The term Cerebral Amyloid Angiopathy (CAA) refers to a group of neurovascular disorders characterized by amyloid deposition within the walls of leptomeningeal and cortical blood vessels of the brain, with specific predilection for arterioles, and (less often) capillaries and veins. Most CAA cases in the general population are sporadic in nature, and represent primarily an age-related condition affecting individuals in the fifth decade of life and beyond. Sporadic CAA is caused by deposition of amyloid-β (Aβ), originating from proteolytic cleavage of the Amyloid Precursor Protein (APP), within the walls of cerebral small caliber vessels. However, hereditary forms of CAA have also been described, generally presenting as rare familial disorder with monogenic (predominantly autosomal dominant) inheritance patterns. Hereditary CAA forms tend to affect younger individuals, and their course and clinical progression is more severe. Studies to date primarily focused on the vascular manifestations of sporadic and hereditary CAA, chiefly symptomatic lobar Intracerebral Hemorrhage (ICH). However, in the past decade sporadic CAA has also been consistently linked to progressive neurocognitive, neurobehavioral, and neuropsychiatric symptoms. This systematic review focuses on the genetics, pathogenesis, neuroimaging, neuropathology, and clinical manifestations of hereditary CAA with specific emphasis on previously overlooked cognitive, behavioral, and psychiatric symptoms.
Collapse
|
20
|
Voigt S, Amlal S, Koemans EA, Rasing I, van Etten ES, van Zwet EW, van Buchem MA, Terwindt GM, van Walderveen MA, Wermer MJ. Spatial and temporal intracerebral hemorrhage patterns in Dutch-type hereditary cerebral amyloid angiopathy. Int J Stroke 2021; 17:793-798. [PMID: 34791949 PMCID: PMC9373023 DOI: 10.1177/17474930211057022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aim To investigate whether there is a topographical and temporal pattern of index
and recurrent intracerebral hemorrhages (ICH) in Dutch-type hereditary
Cerebral Amyloid Angiopathy (D-CAA) to increase our understanding on
CAA-related ICH development. Methods We included patients with DNA confirmed D-CAA or a history with ≥1 lobar ICH
and ≥1 first-degree relative with D-CAA. Topographical pattern was studied
by location (proportion frontal/parietal/temporal/occipital;
infra/supratentorial and occurrence ratios relative to lobe volume) and
volume of index and recurrent ICHs were determined on CT. Temporal pattern
was examined by time between recurrent ICHs was retrieved from medical
records. Results We included 72 patients with D-CAA (mean age at index ICH 55 years) with in
total 214 ICH. The median follow-up time was 7 years (range 0.8 to 28
years). All ICH were lobar and supratentorial. The index ICH was most
frequently located in the occipital lobe (34% vs. 22% in the other three
lobes; with index ICH occurrence ratios relative to lobe volume of 1.9 for
occipital, 1.0 for temporal, 1.2 for parietal, and 0.5 for frontal,
p = 0.001). In 16/47 (34%) patients with multiple ICH, the second ICH was
located in the same lobe as the index ICH. The median time-interval between
subsequent ICH was #1-2 ICH 27 months, #2-3 ICH 14 months, and #3-4 ICH 7
months (p = 0.6) There was no difference in volume between index and
recurrent ICHs. Conclusions We found that index and recurrent ICHs in D-CAA have a preference for the
occipital lobe and are least frequent in the frontal lobe, which adds to the
existing knowledge of histopathological studies on amyloid load in CAA.
Surprisingly, there was no acceleration in time nor gradual increase of
hematoma volume between subsequent ICHs.
Collapse
Affiliation(s)
- Sabine Voigt
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Siham Amlal
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Emma A Koemans
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Ingeborg Rasing
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | | | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands
| |
Collapse
|
21
|
Gender differences in long-term mortality after spontaneous intracerebral hemorrhage in southern Portugal. Porto Biomed J 2021; 6:e137. [PMID: 34368489 PMCID: PMC8341340 DOI: 10.1097/j.pbj.0000000000000137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 02/07/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: the prognosis of spontaneous intracerebral hemorrhage (SICH) remains poor. Understanding gender differences can clarify the clinico-epidemiological and process of care related factors that influence SICH prognosis. We analyzed the long-term gender differences of mortality after SICH in Algarve, southern Portugal. Patients and Methods: analysis of consecutive community representative of SICH survivors (2009–2015). Logistic regression analysis and Kaplan–Meier method was used to assess gender differences on 1-year mortality and survival. We further analyzed if differences exist between 4 age and gender based subgroups (women <75 years, women ≥75 years, men <75 years, men ≥75 years). Results: a total of 285 survivors were analyzed; majority men (66.3%). Women were 2 years older on average. Overall case fatality was 11.6% [CI: 8.3–15.8]. A non-statistically significant (P = .094) higher case-fatality rate was observed in women; men were more frequently admitted to stroke unit; women had more often poor functional outcome or modified Rankin scale (mRS) ≥3. Predictors of death were: being women with ≥ 75 years, in-hospital pneumonia and hospital discharge mRS ≥3. The likelihood of death was higher in women ≥75 years (OR = 2.91 [1.23–8.1], P = .035) in comparison to women <75 years and men ≥75 years. Women <75 years had the longest survivor time, whereas women ≥75 years the shortest survivor time (P < .001). Conclusion: gender and age interact to influence long-term mortality after SICH. Women ≥75 years are at increased risk of death and have reduced survival after SICH in southern Portugal. Further studies are needed to clarify the biological or social factors contributing for the poor prognosis in the very old women in the region.
Collapse
|
22
|
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: 92] [Impact Index Per Article: 30.7] [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.
Collapse
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
| |
Collapse
|
23
|
Morais Filho ABD, Rego TLDH, Mendonça LDL, Almeida SSD, Nóbrega MLD, Palmieri TDO, Giustina GZD, Melo JP, Pinheiro FI, Guzen FP. The physiopathology of spontaneous hemorrhagic stroke: a systematic review. Rev Neurosci 2021; 32:631-658. [PMID: 33594841 DOI: 10.1515/revneuro-2020-0131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/22/2021] [Indexed: 12/29/2022]
Abstract
Hemorrhagic stroke (HS) is a major cause of death and disability worldwide, despite being less common, it presents more aggressively and leads to more severe sequelae than ischemic stroke. There are two types of HS: Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH), differing not only in the site of bleeding, but also in the mechanisms responsible for acute and subacute symptoms. This is a systematic review of databases in search of works of the last five years relating to the comprehension of both kinds of HS. Sixty two articles composed the direct findings of the recent literature and were further characterized to construct the pathophysiology in the order of events. The road to the understanding of the spontaneous HS pathophysiology is far from complete. Our findings show specific and individual results relating to the natural history of the disease of ICH and SAH, presenting common and different risk factors, distinct and similar clinical manifestations at onset or later days to weeks, and possible complications for both.
Collapse
|
24
|
van Etten ES, Kaushik K, van Zwet EW, Voigt S, van Walderveen MAA, van Buchem MA, Terwindt GM, Wermer MJH. Sensitivity of the Edinburgh Criteria for Lobar Intracerebral Hemorrhage in Hereditary Cerebral Amyloid Angiopathy. Stroke 2020; 51:3608-3612. [PMID: 33148142 DOI: 10.1161/strokeaha.120.031264] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Edinburgh computed tomography and genetic criteria enable diagnosis of cerebral amyloid angiopathy (CAA) associated lobar intracerebral hemorrhage (ICH) but have not been validated in living patients. We assessed the sensitivity of the Edinburgh criteria in patients with acute lobar ICH due to Dutch-type hereditary CAA; a genetic and pure form of CAA. METHODS We retrospectively analyzed computed tomography-scans from a cohort of consecutive Dutch-type hereditary CAA patients who presented with ≥1 episode(s) of acute lobar ICH at the Leiden University Medical Center. Presence of subarachnoid hemorrhage (SAH) and finger-like projections (FLP) were determined. Association of SAH and FLP with ICH volume was analyzed using multivariate linear regression. RESULTS We included 55 Dutch-type hereditary CAA patients (mean age 56 years, 55% men) with a total of 107 episodes of acute lobar ICH. SAH was present in 82/107 (76%) and FLP in 62/107 (58%), resulting in a sensitivity of 76% for SAH and 58% for FLP. In 56 (52%), both markers were present. Nineteen (18%) lobar ICH showed no SAH extension or FLP. ICH volume was significantly associated with presence of SAH (median volume 4 versus 28 mL; P=0.001) and presence of FLP (median volume 7 versus 39 mL; P<0.001). With an ICH volume of ≥40 mL, the sensitivity of the presence of both SAH and FLP was >81% (95% CI, 70%-92%), whereas in ICH volumes <15 mL the sensitivity was <50%. CONCLUSIONS The computed tomography-based Edinburgh criteria seem to be a sensitive diagnostic test for CAA-associated lobar ICH, although they should be used with caution in small-sized lobar ICH.
Collapse
Affiliation(s)
- Ellis S van Etten
- Department of Neurology (E.S.v.E., K.K., S.V., G.M.T., M.J.H.W.), Leiden University Medical Center, Leiden, the Netherlands
| | - Kanishk Kaushik
- Department of Neurology (E.S.v.E., K.K., S.V., G.M.T., M.J.H.W.), Leiden University Medical Center, Leiden, the Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z.), Leiden University Medical Center, Leiden, the Netherlands
| | - Sabine Voigt
- Department of Neurology (E.S.v.E., K.K., S.V., G.M.T., M.J.H.W.), Leiden University Medical Center, Leiden, the Netherlands
| | | | - Mark A van Buchem
- Department of Radiology (M.A.A.v.W., M.A.v.B.), Leiden University Medical Center, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology (E.S.v.E., K.K., S.V., G.M.T., M.J.H.W.), Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology (E.S.v.E., K.K., S.V., G.M.T., M.J.H.W.), Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
25
|
Kubiszewski P, Sugita L, Kourkoulis C, DiPucchio Z, Schwab K, Anderson CD, Gurol ME, Greenberg SM, Viswanathan A, Rosand J, Biffi A. Association of Selective Serotonin Reuptake Inhibitor Use After Intracerebral Hemorrhage With Hemorrhage Recurrence and Depression Severity. JAMA Neurol 2020; 78:2770031. [PMID: 32865558 PMCID: PMC7489430 DOI: 10.1001/jamaneurol.2020.3142] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/19/2020] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat poststroke depression but are associated with increased incidence of first-ever intracerebral hemorrhage (ICH) in the general population. The decision to treat ICH survivors with SSRIs must therefore balance potential risks of ICH recurrence with presumed benefits on depressive symptoms. OBJECTIVE To determine whether SSRI use among survivors of primary ICH was associated with ICH recurrence and decreased severity of depressive symptoms. DESIGN, SETTING, AND PARTICIPANTS Longitudinal ICH cohort study at a tertiary care center enrolling from January 2006 to December 2017, with follow-up for a median of 53.2 months (interquartile range, 42.3-61.2 months). The study included 1279 consenting individuals (1049 White, 89 Black, 77 Hispanic, and 64 other race/ethnicity) of 1335 eligible patients presenting with primary ICH and who were discharged alive from initial hospitalization for stroke. MAIN OUTCOMES AND MEASURES We conducted univariable and multivariable analyses for ICH recurrence risk and depression severity, including subset analyses for patients with 1 or more of the following characteristics associated with high ICH recurrence risk: (1) lobar ICH; (2) presence of the apolipoprotein ε2/ε4 gene variants; (3) prior history of ICH/TIA/ischemic stroke; and (4) Black or Hispanic race/ethnicity. RESULTS Mean age of study participants was 71.3 years, with 602 women (47%); of the 1279 participants, 1049 were White, 89 were Black, 77 were Hispanic, and 64 were other race/ethnicity. SSRI exposure was associated with both ICH recurrence (subhazard ratio [SHR], 1.31; 95% CI, 1.08-1.59) and resolution of post-ICH depression (SHR, 1.53; 95% CI, 1.12 2.09). Among those individuals at high risk for recurrent ICH, SSRIs were associated with further elevation in risk for ICH recurrence (SHR, 1.79; 95% CI, 1.22-2.64) compared with all other survivors of ICH (SHR, 1.20; 95% CI, 1.01-1.42; P = .008 for comparison of effect sizes). The association of SSRI with reduced depressive symptoms did not differ between high those at high risk for recurrent ICH and all other ICH survivors. CONCLUSIONS AND RELEVANCE Selective serotonin reuptake inhibitor exposure after ICH is associated with both improvement in depressive symptoms and increased risk of recurrent hemorrhagic stroke. Clinical history, neuroimaging data, and genetic biomarkers may help to identify survivors of ICH more likely to safely tolerate SSRI use.
Collapse
Affiliation(s)
- Patryk Kubiszewski
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lansing Sugita
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christina Kourkoulis
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Zora DiPucchio
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristin Schwab
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher D. Anderson
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
| | - M. Edip Gurol
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven M. Greenberg
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Alessandro Biffi
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
26
|
Angiopatia amiloide cerebrale sporadica. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
27
|
Patel N, Banahan C, Janus J, Horsfield MA, Cox A, Li X, Cappellugola L, Colman J, Egan V, Garrard P, Chung EM. Perioperative Cerebral Microbleeds After Adult Cardiac Surgery. Stroke 2019; 50:336-343. [PMID: 30572811 PMCID: PMC6354910 DOI: 10.1161/strokeaha.118.023355] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background and Purpose- Cerebral microbleeds (CMBs) have been observed using magnetic resonance imaging in patients with cardiovascular risk factors, cognitive deterioration, small vessel disease, and dementia. They are a well-known consequence of cerebral amyloid angiopathy, chronic hypertension, and diffuse axonal injury, among other causes. However, the frequency and location of new CMBs postadult cardiac surgery, in association with cognition and perioperative risk factors, have yet to be studied. Methods- Pre- and postsurgery magnetic resonance susceptibility-weighted images and neuropsychological tests were analyzed from a total of 75 patients undergoing cardiac surgery (70 men; mean age, 63±10 years). CMBs were identified by a neuroradiologist blinded to clinical details who independently assessed the presence and location of CMBs using standardized criteria. Results- New CMBs were identified in 76% of patients after cardiac surgery. The majority of new CMBs were located in the frontal lobe (46%) followed by the parietal lobe (15%), cerebellum (13%), occipital lobe (12%), and temporal lobe (8%). Patients with new CMBs typically began with a higher prevalence of preexisting CMBs ( P=0.02). New CMBs were associated with longer cardiopulmonary bypass times ( P=0.003), and there was a borderline association with lower percentage hematocrit ( P=0.04). Logistic regression analysis suggested a ≈2% increase in the odds of acquiring new CMBs during cardiac surgery for every minute of bypass time (odds ratio, 1.02; 95% CI, 1.00-1.05; P=0.04). Postoperative neuropsychological decline was observed in 44% of patients and seemed to be unrelated to new CMBs. Conclusions- New CMBs identified using susceptibility-weighted images were found in 76% of patients who underwent cardiac surgery. CMBs were globally distributed with the highest numbers in the frontal and parietal lobes. Our regression analysis indicated that length of cardiopulmonary bypass time and lowered hematocrit may be significant predictors for new CMBs after cardiac surgery. Clinical Trial Registration- URL: http://www.isrctn.com . Unique identifier: 66022965.
Collapse
Affiliation(s)
- Nikil Patel
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
- NIHR Leicester Biomedical Research Centre–Cardiovascular Theme, Glenfield Hospital, United Kingdom (N.P., E.M.L.C.)
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Caroline Banahan
- Department of Medical Physics, University Hospitals of Leicester NHS Trust, United Kingdom (C.B., E.M.L.C.)
| | - Justyna Janus
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Mark A. Horsfield
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Anthony Cox
- Neuroradiology Department, St George’s Hospital, London, United Kingdom (A.C.)
| | - Xingfeng Li
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Laurie Cappellugola
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Jordan Colman
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Vincent Egan
- Department of Psychiatry and Applied Psychology, University of Nottingham, United Kingdom (V.E.)
| | - Peter Garrard
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Emma M.L. Chung
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
- NIHR Leicester Biomedical Research Centre–Cardiovascular Theme, Glenfield Hospital, United Kingdom (N.P., E.M.L.C.)
- Department of Medical Physics, University Hospitals of Leicester NHS Trust, United Kingdom (C.B., E.M.L.C.)
| |
Collapse
|
28
|
Kaiser J, Schebesch KM, Brawanski A, Linker RA, Schlachetzki F, Wagner A. Long-Term Follow-Up of Cerebral Amyloid Angiopathy-Associated Intracranial Hemorrhage Reveals a High Prevalence of Atrial Fibrillation. J Stroke Cerebrovasc Dis 2019; 28:104342. [PMID: 31521517 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/17/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022] Open
Abstract
GOAL Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. MATERIAL AND METHODS We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. FINDINGS Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least "possible CAA." Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. CONCLUSIONS Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.
Collapse
Affiliation(s)
- Johanna Kaiser
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Alexander Brawanski
- Department of Neurosurgery, University Clinic Regensburg, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Andrea Wagner
- Department of Neurology, University of Regensburg, Regensburg, Germany.
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Sembill JA, Kuramatsu JB, Hohnloser SH, Huttner HB. Management von intrazerebralen Blutungen unter oraler Antikoagulation. Herz 2019; 44:315-323. [DOI: 10.1007/s00059-019-4802-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
31
|
Sembill JA, Kuramatsu JB, Schwab S, Huttner HB. Resumption of oral anticoagulation after spontaneous intracerebral hemorrhage. Neurol Res Pract 2019; 1:12. [PMID: 33324878 PMCID: PMC7650131 DOI: 10.1186/s42466-019-0018-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023] Open
Abstract
Background Given an ageing population the incidence of both patients suffering from intracerebral hemorrhage (ICH) and those requiring oral anticoagulation will increase. Up to now there are no results from randomized trials available whether or not, and when, ICH survivors should resume OAC. This review summarizes the most important observational studies, and initiated ongoing trials, to help guiding physicians in daily routine decision making. Findings Several large observational studies and meta-analyses verified that OAC resumption was associated with a significant reduction of thromboembolic complications and mortality without leading to increased rates of recurrent ICH. OAC resumption seemed further associated with improved functional recovery and favorable long-term outcome. Given the general bleeding risk reduction in patients using Non–vitamin K antagonist oral anticoagulants (NOAC) compared to Vitamin-K-antagonist (VKA), NOAC use should also be preferred after ICH, although specific comparative studies are pending. Patients with lobar ICH need special attention as these patients showed increased ICH recurrence rates, why decision making should include extended diagnostic work-up evaluating cerebral microbleed burden, cortical subarachnoid hemorrhage and superficial siderosis. Further, patients with mechanical heart valves need specific consideration as restarting VKA may be unsafe until two weeks, whereas optimal balancing of hemorrhagic with thromboembolic complications may allow earlier re-initiation one week after ICH. In patients with atrial fibrillation, resumption generally should take place between 4 and 8 weeks after ICH depending on a patient’s individual risk profile. Left atrial appendage occlusion (LAAO) might represent an alternative strategy in high-risk patients. Ongoing clinical trials will clarify whether OAC resumption versus LAAO versus no antithrombotic therapy may represent the best possible secondary stroke prevention in ICH survivors with atrial fibrillation. Conclusions According to observational data OAC resumption after ICH seems beneficial and safe. Ongoing clinical trials will create evidence regarding treatment effects of pharmaceutical resumption and interventional alternatives. Yet, individual decision making weighing the patient’s individual thromboembolic versus hemorrhagic risks remains essential.
Collapse
Affiliation(s)
- Jochen A Sembill
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| |
Collapse
|
32
|
Kuramatsu JB, Huttner HB. Management of oral anticoagulation after intracerebral hemorrhage. Int J Stroke 2019; 14:238-246. [PMID: 30762497 DOI: 10.1177/1747493019828555] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The most recent years have significantly expanded knowledge regarding risks and benefits of resuming oral anticoagulation (OAC) after intracerebral hemorrhage (ICH). No randomized data is yet available, though several large observational studies and meta-analyses have investigated the impact of resuming OAC on thromboembolic versus hemorrhagic complications in these high-risk patients after ICH. AIMS The present review will summarize the most important studies conducted over the last years and will focus on relevant factors help guiding on decision-making on whether to start OAC after ICH. SUMMARY OF REVIEW Several important factors (demographic, co-morbidities, clinical characteristics) need to be considered before individual decision-making for or against OAC is employed. Existing observational data suggest that patients after ICH with indication for long-term oral anticoagulation benefit from OAC given significant reductions of thromboembolic events without significantly increasing bleeding complications. Studies even suggest that thereby also clinical outcomes may be improved. Prospective trials currently recruiting patients will clarify whether OAC after ICH - or left atrial appendage closure as a meaningful alternative - is of clinical net-benefit. CONCLUSIONS Large sized and well-executed investigations (moderate quality of evidence) are showing that OAC resumption after ICH decreases thromboembolic complications and long-term mortality without significantly increasing bleeding complications. Further, data suggest that resumption may be safer in non-lobar ICH compared to lobar ICH, but overall, thoughtful selection, strict blood pressure control, and precise communication are paramount before starting a patient on OAC after ICH.
Collapse
Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| |
Collapse
|
33
|
The Clinical Dilemma of Anticoagulation Use in Patients with Cerebral Amyloid Angiopathy and Atrial Fibrillation. Curr Cardiol Rep 2018; 20:106. [DOI: 10.1007/s11886-018-1052-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
34
|
Yan F, Yi Z, Hua Y, Shen Y, Li M, Ding Y, Chandra A, Ji X, Yue W. Predictors of mortality and recurrent stroke within five years of intracerebral hemorrhage. Neurol Res 2018; 40:466-472. [PMID: 30134784 DOI: 10.1080/01616412.2018.1451266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Feng Yan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhang Yi
- Drug Clinical Trial Institution, Tianjin Huanhu Hospital, Tianjin, China
| | - Yang Hua
- Department of Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying Shen
- Department of Traditional Chinese Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Li
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ankush Chandra
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Yue
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Cerebral amyloid angiopathy (CAA) is diagnosed primarily as a cause of lobar intracerebral hemorrhages (ICH) in elderly patients. With improving MRI techniques, however, the role of CAA in causing other symptoms has become clear. Recognizing the full clinical spectrum of CAA is important for diagnosis and treatment. In this review we summarize recent insights in clinical CAA features, MRI biomarkers, and management. RECENT FINDINGS The rate of ICH recurrence in CAA is among the highest of all stroke subtypes. Cortical superficial siderosis (cSS) and cortical subarachnoid hemorrhage (cSAH) are important imaging predictors for recurrent ICH. CAA also causes cognitive problems in multiple domains. In patients with nondemented CAA, the risk of developing dementia is high especially after ICH. CAA pathology probably starts years before the first clinical manifestations. The first signs in hereditary CAA are white matter lesions, cortical microinfarcts, and impaired occipital cerebral vasoreactivity. Visible centrum semiovale perivascular spaces, lobar located lacunes, and cortical atrophy are new nonhemorrhagic MRI markers. SUMMARY CAA should be in the differential diagnosis of elderly patients with lobar ICH but also in those with cognitive decline and episodic transient neurological symptoms. Physicians should be aware of the cognitive effects of CAA. In patients with a previous ICH, cSS, or cSAH, anticoagulation should be considered risky. The increasing number of MRI markers may help to discriminate CAA from other small vessel diseases and dementia subtypes.
Collapse
|
36
|
Tsai HH, Kim JS, Jouvent E, Gurol ME. Updates on Prevention of Hemorrhagic and Lacunar Strokes. J Stroke 2018; 20:167-179. [PMID: 29886717 PMCID: PMC6007298 DOI: 10.5853/jos.2018.00787] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/16/2018] [Accepted: 05/23/2018] [Indexed: 12/22/2022] Open
Abstract
Intracerebral hemorrhage (ICH) and lacunar infarction (LI) are the major acute clinical manifestations of cerebral small vessel diseases (cSVDs). Hypertensive small vessel disease, cerebral amyloid angiopathy, and hereditary causes, such as Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), constitute the three common cSVD categories. Diagnosing the underlying vascular pathology in these patients is important because the risk and types of recurrent strokes show significant differences. Recent advances in our understanding of the cSVD-related radiological markers have improved our ability to stratify ICH risk in individual patients, which helps guide antithrombotic decisions. There are general good-practice measures for stroke prevention in patients with cSVD, such as optimal blood pressure and glycemic control, while individualized measures tailored for particular patients are often needed. Antithrombotic combinations and anticoagulants should be avoided in cSVD treatment, as they increase the risk of potentially fatal ICH without necessarily lowering LI risk in these patients. Even when indicated for a concurrent pathology, such as nonvalvular atrial fibrillation, nonpharmacological approaches should be considered in the presence of cSVD. More data are emerging regarding the presentation, clinical course, and diagnostic markers of hereditary cSVD, allowing accurate diagnosis, and therefore, guiding management of symptomatic patients. When suspicion for asymptomatic hereditary cSVD exists, the pros and cons of prescribing genetic testing should be discussed in detail in the absence of any curative treatment. Recent data regarding diagnosis, risk stratification, and specific preventive approaches for both sporadic and hereditary cSVDs are discussed in this review article.
Collapse
Affiliation(s)
- Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eric Jouvent
- Department of Neurology, University Paris Diderot, Paris, France
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
37
|
Malik MT, Myers C, Kazmi SJ, Zand R. Recurrent Intracerebral Hemorrhage after Exercise in a Young Patient Presenting with Sporadic Cerebral Amyloid Angiopathy in a Young Patient. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2017; 9:12-13. [PMID: 29445432 PMCID: PMC5805902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cerebral Amyloid Angiopathy (CAA) is one of the significant causes of lobar intracerebral hemorrhage (ICH) mainly among elderly people. Sporadic cases of CAA have been linked to genetic polymorphisms with an increased risk of disease, an earlier presentation, and an accelerated pathology [1]. Here, we present a patient with no significant risk factors who had a recurrent intracerebral hemorrhage secondary to CAA probably induced by exercise.
Collapse
Affiliation(s)
| | - Corey Myers
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | | | - Ramin Zand
- Geisinger Medical Center, Danville, PA, USA
| |
Collapse
|
38
|
Banerjee G, Carare R, Cordonnier C, Greenberg SM, Schneider JA, Smith EE, Buchem MV, Grond JVD, Verbeek MM, Werring DJ. The increasing impact of cerebral amyloid angiopathy: essential new insights for clinical practice. J Neurol Neurosurg Psychiatry 2017; 88:982-994. [PMID: 28844070 PMCID: PMC5740546 DOI: 10.1136/jnnp-2016-314697] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/26/2017] [Accepted: 05/18/2017] [Indexed: 12/29/2022]
Abstract
Cerebral amyloid angiopathy (CAA) has never been more relevant. The last 5 years have seen a rapid increase in publications and research in the field, with the development of new biomarkers for the disease, thanks to advances in MRI, amyloid positron emission tomography and cerebrospinal fluid biomarker analysis. The inadvertent development of CAA-like pathology in patients treated with amyloid-beta immunotherapy for Alzheimer's disease has highlighted the importance of establishing how and why CAA develops; without this information, the use of these treatments may be unnecessarily restricted. Our understanding of the clinical and radiological spectrum of CAA has continued to evolve, and there are new insights into the independent impact that CAA has on cognition in the context of ageing and intracerebral haemorrhage, as well as in Alzheimer's and other dementias. While the association between CAA and lobar intracerebral haemorrhage (with its high recurrence risk) is now well recognised, a number of management dilemmas remain, particularly when considering the use of antithrombotics, anticoagulants and statins. The Boston criteria for CAA, in use in one form or another for the last 20 years, are now being reviewed to reflect these new wide-ranging clinical and radiological findings. This review aims to provide a 5-year update on these recent advances, as well as a look towards future directions for CAA research and clinical practice.
Collapse
Affiliation(s)
- Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Roxana Carare
- Division of Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Charlotte Cordonnier
- Department of Neurology, Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Steven M Greenberg
- J P Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie A Schneider
- Departments of Pathology and Neurological Sciences, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mark van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen van der Grond
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel M Verbeek
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.,Departments of Neurology and Laboratory Medicine, Radboud Alzheimer Center, Nijmegen, The Netherlands
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
39
|
DeSimone CV, Graff-Radford J, El-Harasis MA, Rabinstein AA, Asirvatham SJ, Holmes DR. Cerebral Amyloid Angiopathy: Diagnosis, Clinical Implications, and Management Strategies in Atrial Fibrillation. J Am Coll Cardiol 2017; 70:1173-1182. [PMID: 28838368 DOI: 10.1016/j.jacc.2017.07.724] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 01/16/2023]
Abstract
With an aging population, clinicians are more frequently encountering patients with atrial fibrillation who are also at risk of intracerebral hemorrhage due to cerebral amyloid angiopathy, the result of β-amyloid deposition in cerebral vessels. Cerebral amyloid angiopathy is common among elderly patients, and is associated with an increased risk of intracerebral bleeding, especially with the use of anticoagulation. Despite this association, this entity is absent in current risk-benefit analysis models, which may result in underestimation of the chance of bleeding in the subset of patients with this disease. Determining the presence and burden of cerebral amyloid angiopathy is particularly important when planning to start or restart anticoagulation after an intracerebral hemorrhage. Given the lack of randomized trial data to guide management strategies, we discuss a heart-brain team approach that includes clinician-patient shared decision making for the use of pharmacologic and nonpharmacologic approaches to diminish stroke risk.
Collapse
Affiliation(s)
| | | | | | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
40
|
DeSimone CV, Graff-Radford J, El-Harasis MA, Rabinstein AA, Asirvatham SJ, Holmes DR. Cerebral amyloid angiopathy and implications for atrial fibrillation management. Lancet 2017; 390:9-11. [PMID: 28677558 DOI: 10.1016/s0140-6736(17)31326-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/26/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Christopher V DeSimone
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | | - Majd A El-Harasis
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA; Division of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| |
Collapse
|