Cerebral amyloid angiopathy-related cardiac injury: Focus on cardiac cell death

Advancements in investigating the role of cerebral small vein loss in Alzheimer's disease-related pathological changes

Alzheimer's disease (AD) is the prevailing type of dementia in the elderly, yet a comprehensive comprehension of its precise underlying mechanisms remains elusive. The investigation of the involvement of cerebral small veins in the advancement of AD has yet to be sufficiently explored in previous studies, primarily due to constraints associated with pathological staining techniques. However, recent research has provided valuable insights into multiple pathophysiological occurrences concerning cerebral small veins in AD, which may manifest sequentially, concurrently, or in a self-perpetuating manner. These events are presumed to be among the initial processes in the disease's progression. The impact of cerebral small vein loss on amyloid beta (Aβ) clearance through the glial lymphatic system is noteworthy. There exists a potential interdependence between collagen deposition and Aβ deposition in cerebral small veins. The compromised functionality of cerebral small veins can result in decreased cerebral perfusion pressure, potentially leading to cerebral tissue ischemia and edema. Additionally, the reduction of cerebral small veins may facilitate the infiltration of inflammatory factors into the brain parenchyma, thereby eliciting neuroinflammatory responses. Susceptibility-weighted imaging (SWI) is a valuable modality for the efficient assessment of cerebral small veins, precisely the deep medullary vein (DMV), and holds promise for the identification of precise and reliable imaging biomarkers for AD. This review presents a comprehensive overview of the current advancements and obstacles to the impairment of cerebral small veins in AD. Additionally, we emphasize future research avenues and the importance of conducting further investigations in this domain.

When Atrial Fibrillation Meets Cerebral Amyloid Angiopathy: Current Evidence and Strategies

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.

Case Report: Postmortem brain and heart pathology unveiling the pathogenesis of coexisting acute ischemic stroke and electrocardiographic abnormality

Electrocardiography abnormalities have been occasionally reported at the onset of stroke. Simultaneous electrocardiographic abnormalities and stroke require a rapid differentiated diagnosis among several diseases. However, direct causal relationships remain unclear. A 92-year-old woman presented to our emergency department in a sudden-onset coma. The patient suffered from huge acute ischemic stroke with bilateral internal carotid artery occlusion assessed by brain magnetic resonance imaging, and her electrocardiography showed ST-segment elevation at II, III, aVF and V4-6, and atrial fibrillation (AF). However, the etiology of the medical condition was clinically unknown. Eventually, the patient died on day 4 of hospitalization before the diagnosis could be completed. Therefore, an autopsy was performed to investigate pathological findings after obtaining informed consent from the family. A postmortem pathological evaluation demonstrated that fibrin mural thrombi in the left atrial appendage (LAA), and the cerebral and coronary arteries possessed CD31-positive endothelial cells, and CD68-positive and CD168-positive macrophages in a similar fashion, suggesting the fibrin thrombi observed in the three sites implicated to be identical. We concluded that nearly concurrent cerebral and coronary artery embolism because of the fibrin thrombi in LAA developed by AF. Simultaneous cerebral infarction and myocardial infarction are referred to as cardiocerebral infarction (CCI), a rare disorder for which clear pathomechanisms remain unknown, although several mechanisms of CCI have been proposed. We first revealed the clear pathology of CCI using the autopsy. Additional pathological studies are warranted to establish clear pathomechanisms and preventive strategies of CCI.