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Charidimou A, Boulouis G. Core CSF Biomarker Profile in Cerebral Amyloid Angiopathy: Updated Meta-Analysis. Neurology 2024; 103:e209795. [PMID: 39270153 DOI: 10.1212/wnl.0000000000209795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There is a clear need to characterize and validate molecular biomarkers of cerebral amyloid angiopathy (CAA), in an effort to improve diagnostics, especially in the context of patients with Alzheimer disease (AD) receiving immunotherapies (for whom underlying CAA is the driver of amyloid-related imaging abnormalities). We performed an updated meta-analysis of 5 core CSF biomarkers (Aβ42, Aβ40, Aβ438, total tau [T-tau], and phosphorylated tau [P-tau]) to assess which of these are most altered in sporadic CAA. METHODS We systematically searched PubMed for eligible studies reporting data on CSF biomarkers reflecting APP metabolism (Aβ42, Aβ40, Aβ38), neurodegeneration (T-tau), and tangle pathology (P-tau), in symptomatic sporadic CAA cohorts (based on the Boston criteria) vs control groups and/or vs patients with AD. Biomarker performance was assessed in random-effects meta-analysis based on ratio of mean (RoM) biomarker concentrations in (1) patients with CAA to controls and (2) CAA to patients with AD. RoM >1 indicates higher biomarker concentration in CAA vs comparison population, and RoM <1 indicates higher concentration in comparison groups. RESULTS 8 studies met inclusion criteria: a total of 11 CAA cohorts (n = 289), 9 control cohorts (n = 310), and 8 AD cohorts (n = 339). Overall included studies were of medium quality based on our assessment tools. CAA to controls had lower mean level of all amyloid markers with CSF Aβ42, Aβ40, and Aβ38 RoMs of 0.46 (95% CI 0.38-0.55, p < 0.0001), 0.70 (95% CI 0.63-0.78, p < 0.0001), and 0.71 (95% CI 0.56-0.89, p = 0.003), respectively. CSF T-tau and P-tau RoMs of patients with CAA to controls were both greater than 1: 1.56 (95% CI 1.32-1.84, p < 0.0001) and 1.31 (95% CI 1.13-1.51, p < 0.0001), respectively. Differentiation between CAA and AD was strong for CSF Aβ40 (RoM 0.76, 95% CI 0.69-0.83, p < 0.0001) and Aβ38 (RoM 0.55, 95% CI 0.38-0.81, p < 0.0001), but not Aβ42 (RoM 1.00; 95% CI 0.81-1.23, p = 0.970). For T-tau and P-tau, average CSF ratios in patients with CAA vs AD were 0.64 (95% CI 0.58-0.71, p < 0.0001) and 0.64 (95% CI 0.58-0.71, p < 0.0001), respectively. DISCUSSION Specific CSF patterns of Aβ42, Aβ40, Aβ38, T-tau, and P-tau might serve as molecular biomarkers of CAA, in research and clinical settings, offering the potential to improve the clinical diagnostic approach pathway in specific scenarios.
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Affiliation(s)
- Andreas Charidimou
- From the Department of Neurology (A.C.), Boston University Medical Center, Boston University School of Medicine, MA; and Diagnostic and Interventional Neuroradiology (G.B.), University Hospital, Tours, France
| | - Gregoire Boulouis
- From the Department of Neurology (A.C.), Boston University Medical Center, Boston University School of Medicine, MA; and Diagnostic and Interventional Neuroradiology (G.B.), University Hospital, Tours, France
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van den Berg E, Kersten I, Brinkmalm G, Johansson K, de Kort AM, Klijn CJ, Schreuder FH, Gobom J, Stoops E, Portelius E, Gkanatsiou E, Zetterberg H, Blennow K, Kuiperij HB, Verbeek MM. Profiling amyloid-β peptides as biomarkers for cerebral amyloid angiopathy. J Neurochem 2024; 168:1254-1264. [PMID: 38362804 PMCID: PMC11260253 DOI: 10.1111/jnc.16074] [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] [Received: 10/25/2023] [Revised: 01/08/2024] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
Brain amyloid-β (Aβ) deposits are key pathological hallmarks of both cerebral amyloid angiopathy (CAA) and Alzheimer's disease (AD). Microvascular deposits in CAA mainly consist of the Aβ40 peptide, whereas Aβ42 is the predominant variant in parenchymal plaques in AD. The relevance in pathogenesis and diagnostic accuracy of various other Aβ isoforms in CAA remain understudied. We aimed to investigate the biomarker potential of various Aβ isoforms in cerebrospinal fluid (CSF) to differentiate CAA from AD pathology. We included 25 patients with probable CAA, 50 subjects with a CSF profile indicative of AD pathology (AD-like), and 23 age- and sex-matched controls. CSF levels of Aβ1-34, Aβ1-37, Aβ1-38, Aβ1-39, Aβ1-40, and Aβ1-42 were quantified by liquid chromatography mass spectrometry. Lower CSF levels of all six Aβ peptides were observed in CAA patients compared with controls (p = 0.0005-0.03). Except for Aβ1-42 (p = 1.0), all peptides were decreased in CAA compared with AD-like subjects (p = 0.007-0.03). Besides Aβ1-42, none of the Aβ peptides were decreased in AD-like subjects compared with controls. All Aβ peptides combined differentiated CAA from AD-like subjects better (area under the curve [AUC] 0.84) than individual peptide levels (AUC 0.51-0.75). Without Aβ1-42 in the model (since decreased Aβ1-42 served as AD-like selection criterion), the AUC was 0.78 for distinguishing CAA from AD-like subjects. CAA patients and AD-like subjects showed distinct disease-specific CSF Aβ profiles. Peptides shorter than Aβ1-42 were decreased in CAA patients, but not AD-like subjects, which could suggest different pathological mechanisms between vascular and parenchymal Aβ accumulation. This study supports the potential use of this panel of CSF Aβ peptides to indicate presence of CAA pathology with high accuracy.
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Affiliation(s)
- Emma van den Berg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris Kersten
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gunnar Brinkmalm
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kjell Johansson
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Anna M. de Kort
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floris H.B.M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan Gobom
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | | | - Erik Portelius
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eleni Gkanatsiou
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- UK Dementia Research Institute at UCL, London, United Kingdom
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - H. Bea Kuiperij
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel M. Verbeek
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
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Theodorou A, Tsantzali I, Stefanou MI, Sacco S, Katsanos AH, Shoamanesh A, Karapanayiotides T, Koutroulou I, Stamati P, Werring DJ, Cordonnier C, Palaiodimou L, Zompola C, Boviatsis E, Stavrinou L, Frantzeskaki F, Steiner T, Alexandrov AV, Paraskevas GP, Tsivgoulis G. CSF and plasma biomarkers in cerebral amyloid angiopathy: A single-center study and a systematic review/meta-analysis. Eur Stroke J 2024:23969873241260538. [PMID: 38869035 DOI: 10.1177/23969873241260538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION There are limited data regarding cerebrospinal fluid (CSF) and plasma biomarkers among patients with Cerebral Amyloid Angiopathy (CAA). We sought to investigate the levels of four biomarkers [β-amyloids (Aβ42 and Aβ40), total tau (tau) and phosphorylated tau (p-tau)] in CAA patients compared to healthy controls (HC) and patients with Alzheimer Disease (AD). PATIENTS AND METHODS A systematic review and meta-analysis of published studies, including also a 5 year single-center cohort study, with available data on CSF and plasma biomarkers in symptomatic sporadic CAA versus HC and AD was conducted. Biomarkers' comparisons were investigated using random-effects models based on the ratio of mean (RoM) biomarker concentrations. RoM < 1 and RoM > 1 indicate lower and higher biomarker concentration in CAA compared to another population, respectively. RESULTS We identified nine cohorts, comprising 327 CAA patients (mean age: 71 ± 5 years; women: 45%) versus 336 HC (mean age: 65 ± 5 years; women: 45%) and 384 AD patients (mean age: 68 ± 3 years; women: 53%) with available data on CSF biomarkers. CSF Aβ42 levels [RoM: 0.47; 95% CI: 0.36-0.62; p < 0.0001], Aβ40 levels [RoM: 0.70; 95% CI: 0.63-0.79; p < 0.0001] and the ratio Aβ42/Aβ40 [RoM: 0.62; 95% CI: 0.39-0.98; p = 0.0438] differentiated CAA from HC. CSF Aβ40 levels [RoM: 0.73; 95% CI: 0.64-0.83; p = 0.0003] differentiated CAA from AD. CSF tau and p-tau levels differentiated CAA from HC [RoM: 1.71; 95% CI: 1.41-2.09; p = 0.0002 and RoM: 1.44; 95% CI: 1.20-1.73; p = 0.0014, respectively] and from AD [RoM: 0.65; 95% CI: 0.58-0.72; p < 0.0001 and RoM: 0.64; 95% CI: 0.57-0.71; p < 0.0001, respectively]. Plasma Aβ42 [RoM: 1.14; 95% CI: 0.89-1.45; p = 0.2079] and Aβ40 [RoM: 1.07; 95% CI: 0.91-1.25; p = 0.3306] levels were comparable between CAA and HC. CONCLUSIONS CAA is characterized by a distinct CSF biomarker pattern compared to HC and AD. CSF Aβ40 levels are lower in CAA compared to HC and AD, while tau and p-tau levels are higher in CAA compared to HC, but lower in comparison to AD patients.
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Affiliation(s)
- Aikaterini Theodorou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Tsantzali
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, Italy
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Theodoros Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Ioanna Koutroulou
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Polyxeni Stamati
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, Biopolis, Mezourlo Hill, Larissa, Greece
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, France
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lampis Stavrinou
- Second Department of Neurosurgery, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Frantzeska Frantzeskaki
- Second Critical Care Department, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Andrei V Alexandrov
- Department of Neurology, University of Arizona, Banner University Medical Center, Phoenix
| | - Georgios P Paraskevas
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis
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Dargvainiene J, Jensen-Kondering U, Bender B, Berg D, Brüggemann N, Flüh C, Markewitz R, Neumann A, Röben B, Röcken C, Royl G, Schulte C, Wandinger KP, Weiler C, Margraf NG, Kuhlenbäumer G. Aβ38 and Aβ43 do not differentiate between Alzheimer's disease and cerebral amyloid angiopathy. Ann Clin Transl Neurol 2024; 11:806-811. [PMID: 38186185 DOI: 10.1002/acn3.51987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/23/2023] [Accepted: 12/10/2023] [Indexed: 01/09/2024] Open
Abstract
Differential diagnosis between Alzheimer's disease (AD) and cerebral amyloid angiopathy (CAA) using cerebrospinal fluid (CSF) biomarkers is challenging. A recent study suggested that the addition of Aβ38 and Aβ43 to a standard AD biomarker panel (Aβ40, Aβ42, t-tau, p-tau) to improve the differential diagnosis. We tested this hypothesis in an independent German cohort of CAA and AD patients and controls using the same analytical techniques. We found excellent discrimination between AD and controls and between CAA and controls, but not between AD and CAA. Adding Aβ38 and Aβ43 to the panel did not improve the discrimination between AD and CAA.
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Affiliation(s)
- Justina Dargvainiene
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulf Jensen-Kondering
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Benjamin Bender
- Department of Radiology, Diagnostical and Interventional Neuroradiology, University Hospital of Tübingen, Tübingen, Germany
| | - Daniela Berg
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Norbert Brüggemann
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Robert Markewitz
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Benjamin Röben
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Georg Royl
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Schulte
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Caroline Weiler
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Nils G Margraf
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
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Muir RT, Ismail Z, Black SE, Smith EE. Comparative methods for quantifying plasma biomarkers in Alzheimer's disease: Implications for the next frontier in cerebral amyloid angiopathy diagnostics. Alzheimers Dement 2024; 20:1436-1458. [PMID: 37908054 PMCID: PMC10916950 DOI: 10.1002/alz.13510] [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] [Received: 03/12/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 11/02/2023]
Abstract
Plasma amyloid beta (Aβ) and tau are emerging as accessible biomarkers for Alzheimer's disease (AD). However, many assays exist with variable test performances, highlighting the need for a comparative assessment to identify the most valid assays for future use in AD and to apply to other settings in which the same biomarkers may be useful, namely, cerebral amyloid angiopathy (CAA). CAA is a progressive cerebrovascular disease characterized by deposition of Aβ40 and Aβ42 in cortical and leptomeningeal vessels. Novel immunotherapies for AD can induce amyloid-related imaging abnormalities resembling CAA-related inflammation. Few studies have evaluated plasma biomarkers in CAA. Identifying a CAA signature could facilitate diagnosis, prognosis, and a safer selection of patients with AD for emerging immunotherapies. This review evaluates studies that compare the diagnostic test performance of plasma biomarker techniques in AD and cerebrovascular and plasma biomarker profiles of CAA; it also discusses novel hypotheses and future avenues for plasma biomarker research in CAA.
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Affiliation(s)
- Ryan T. Muir
- Calgary Stroke ProgramDepartment of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Zahinoor Ismail
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Department of PsychiatryUniversity of CalgaryCalgaryAlbertaCanada
| | - Sandra E. Black
- Division of NeurologyDepartment of MedicineSunnybrook Health Sciences CentreTorontoOntarioCanada
- LC Campbell Cognitive Neurology Research UnitDr Sandra Black Centre for Brain Resilience and Recovery, and Hurvitz Brain Sciences ProgramSunnybrook Research InstituteUniversity of TorontoTorontoOntarioCanada
| | - Eric E. Smith
- Calgary Stroke ProgramDepartment of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
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Cozza M, Amadori L, Boccardi V. Exploring cerebral amyloid angiopathy: Insights into pathogenesis, diagnosis, and treatment. J Neurol Sci 2023; 454:120866. [PMID: 37931443 DOI: 10.1016/j.jns.2023.120866] [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: 07/03/2023] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
Cerebral Amyloid Angiopathy (CAA) is a neurological disorder characterized by the deposition of amyloid plaques in the walls of cerebral blood vessels. This condition poses significant challenges in terms of understanding its underlying mechanisms, accurate diagnosis, and effective treatment strategies. This article aims to shed light on the complexities of CAA by providing insights into its pathogenesis, diagnosis, and treatment options. The pathogenesis of CAA involves the accumulation of amyloid beta (Aβ) peptides in cerebral vessels, leading to vessel damage, impaired blood flow, and subsequent cognitive decline. Various genetic and environmental factors contribute to the development and progression of CAA, and understanding these factors is crucial for targeted interventions. Accurate diagnosis of CAA often requires advanced imaging techniques, such as magnetic resonance imaging (MRI) or positron emission tomography (PET) scans, to detect characteristic amyloid deposits in the brain. Early and accurate diagnosis enables appropriate management and intervention strategies. Treatment of CAA focuses on preventing further deposition of amyloid plaques, managing associated symptoms, and reducing the risk of complications such as cerebral hemorrhage. Currently, there are no disease-modifying therapies specifically approved for CAA. However, several experimental treatments targeting Aβ clearance and anti-inflammatory approaches are being investigated in clinical trials, offering hope for future therapeutic advancements.
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Affiliation(s)
| | - Lucia Amadori
- Department of Integration, Intermediate Care Programme, AUSL Bologna, Italy
| | - Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, Italy.
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Sin MK, Zamrini E, Ahmed A, Nho K, Hajjar I. Anti-Amyloid Therapy, AD, and ARIA: Untangling the Role of CAA. J Clin Med 2023; 12:6792. [PMID: 37959255 PMCID: PMC10647766 DOI: 10.3390/jcm12216792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Anti-amyloid therapies (AATs), such as anti-amyloid monoclonal antibodies, are emerging treatments for people with early Alzheimer's disease (AD). AATs target amyloid β plaques in the brain. Amyloid-related imaging abnormalities (ARIA), abnormal signals seen on magnetic resonance imaging (MRI) of the brain in patients with AD, may occur spontaneously but occur more frequently as side effects of AATs. Cerebral amyloid angiopathy (CAA) is a major risk factor for ARIA. Amyloid β plays a key role in the pathogenesis of AD and of CAA. Amyloid β accumulation in the brain parenchyma as plaques is a pathological hallmark of AD, whereas amyloid β accumulation in cerebral vessels leads to CAA. A better understanding of the pathophysiology of ARIA is necessary for early detection of those at highest risk. This could lead to improved risk stratification and the ultimate reduction of symptomatic ARIA. Histopathological confirmation of CAA by brain biopsy or autopsy is the gold standard but is not clinically feasible. MRI is an available in vivo tool for detecting CAA. Cerebrospinal fluid amyloid β level testing and amyloid PET imaging are available but do not offer specificity for CAA vs amyloid plaques in AD. Thus, developing and testing biomarkers as reliable and sensitive screening tools for the presence and severity of CAA is a priority to minimize ARIA complications.
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Affiliation(s)
- Mo-Kyung Sin
- College of Nursing, Seattle University, Seattle, WA 98122, USA
| | | | - Ali Ahmed
- VA Medical Center, Washington, DC 20242, USA;
| | - Kwangsik Nho
- School of Medicine, Indianna University, Indianapolis, IN 46202, USA;
| | - Ihab Hajjar
- School of Medicine, University of Texas Southwestern, Dallas, TX 75390, USA;
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8
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Theodorou A, Palaiodimou L, Papagiannopoulou G, Kargiotis O, Psychogios K, Safouris A, Bakola E, Chondrogianni M, Kotsali-Peteinelli V, Melanis K, Tsibonakis A, Andreadou E, Vasilopoulou S, Lachanis S, Velonakis G, Tzavellas E, Tzartos JS, Voumvourakis K, Paraskevas GP, Tsivgoulis G. Clinical Characteristics, Neuroimaging Markers, and Outcomes in Patients with Cerebral Amyloid Angiopathy: A Prospective Cohort Study. J Clin Med 2023; 12:5591. [PMID: 37685658 PMCID: PMC10488273 DOI: 10.3390/jcm12175591] [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: 07/04/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Background and purpose: Sporadic cerebral amyloid angiopathy (CAA) is a small vessel disease, resulting from progressive amyloid-β deposition in the media/adventitia of cortical and leptomeningeal arterioles. We sought to assess the prevalence of baseline characteristics, clinical and radiological findings, as well as outcomes among patients with CAA, in the largest study to date conducted in Greece. Methods: Sixty-eight patients fulfilling the Boston Criteria v1.5 for probable/possible CAA were enrolled and followed for at least twelve months. Magnetic Resonance Imaging was used to assess specific neuroimaging markers. Data regarding cerebrospinal fluid biomarker profile and Apolipoprotein-E genotype were collected. Multiple logistic regression analyses were performed to identify predictors of clinical phenotypes. Cox-proportional hazard regression models were used to calculate associations with the risk of recurrent intracerebral hemorrhage (ICH). Results: Focal neurological deficits (75%), cognitive decline (57%), and transient focal neurological episodes (TFNEs; 21%) were the most common clinical manifestations. Hemorrhagic lesions, including lobar cerebral microbleeds (CMBs; 93%), cortical superficial siderosis (cSS; 48%), and lobar ICH (43%) were the most prevalent neuroimaging findings. cSS was independently associated with the likelihood of TFNEs at presentation (OR: 4.504, 95%CI:1.258-19.088), while multiple (>10) lobar CMBs were independently associated with cognitive decline at presentation (OR:5.418, 95%CI:1.316-28.497). cSS emerged as the only risk factor of recurrent ICH (HR:4.238, 95%CI:1.509-11.900) during a median follow-up of 20 months. Conclusions: cSS was independently associated with TFNEs at presentation and ICH recurrence at follow-up, while a higher burden of lobar CMBs with cognitive decline at baseline. These findings highlight the prognostic value of neuroimaging markers, which may influence clinical decision-making.
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Affiliation(s)
- Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Georgia Papagiannopoulou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Odysseas Kargiotis
- Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (O.K.); (K.P.); (A.S.)
| | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (O.K.); (K.P.); (A.S.)
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece; (O.K.); (K.P.); (A.S.)
| | - Eleni Bakola
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Maria Chondrogianni
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Vasiliki Kotsali-Peteinelli
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Konstantinos Melanis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Athanasios Tsibonakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Elissavet Andreadou
- First Department of Neurology, “Eginition” Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (E.A.); (S.V.)
| | - Sofia Vasilopoulou
- First Department of Neurology, “Eginition” Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (E.A.); (S.V.)
| | - Stefanos Lachanis
- Iatropolis Magnetic Resonance Diagnostic Centre, 15231 Athens, Greece;
| | - Georgios Velonakis
- Second Department of Radiology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Elias Tzavellas
- First Department of Psychiatry, “Aiginition” Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - John S. Tzartos
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Georgios P. Paraskevas
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (L.P.); (G.P.); (E.B.); (M.C.); (V.K.-P.); (K.M.); (A.T.); (J.S.T.); (K.V.); (G.P.P.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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9
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Sembill JA, Lusse C, Linnerbauer M, Sprügel MI, Mrochen A, Knott M, Engelhorn T, Schmidt MA, Doerfler A, Oberstein TJ, Maler JM, Kornhuber J, Lewczuk P, Rothhammer V, Schwab S, Kuramatsu JB. Cerebrospinal fluid biomarkers for cerebral amyloid angiopathy. Brain Commun 2023; 5:fcad159. [PMID: 37389304 PMCID: PMC10300526 DOI: 10.1093/braincomms/fcad159] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/10/2023] [Accepted: 05/17/2023] [Indexed: 07/01/2023] Open
Abstract
Integrating cerebrospinal fluid-biomarkers into diagnostic workup of patients with sporadic cerebral amyloid angiopathy may support early and correct identification. We aimed to identify and validate clinical- and cerebrospinal fluid-biomarkers for in vivo diagnosis of cerebral amyloid angiopathy. This observational cohort study screened 2795 consecutive patients admitted for cognitive complaints to the academic departments of neurology and psychiatry over a 10-year period (2009-2018). We included 372 patients with available hemosiderin-sensitive MR imaging and cerebrospinal fluid-based neurochemical dementia diagnostics, i.e. Aβ40, Aβ42, t-tau, p-tau. We investigated the association of clinical- and cerebrospinal fluid-biomarkers with the MRI-based diagnosis of cerebral amyloid angiopathy, applying confounder-adjusted modelling, receiver operating characteristic and unsupervised cluster analyses. We identified 67 patients with cerebral amyloid angiopathy, 76 patients with Alzheimer's disease, 75 patients with mild cognitive impairment due to Alzheimer's disease, 76 patients with mild cognitive impairment with unlikely Alzheimer's disease and 78 healthy controls. Patients with cerebral amyloid angiopathy showed a specific cerebrospinal fluid pattern: average concentration of Aß40 [13 792 pg/ml (10 081-18 063)] was decreased compared to all controls (P < 0.05); Aß42 [634 pg/ml (492-834)] was comparable to Alzheimer's disease and mild cognitive impairment due to Alzheimer's disease (P = 0.10, P = 0.93) but decreased compared to mild cognitive impairment and healthy controls (both P < 0.001); p-tau [67.3 pg/ml (42.9-91.9)] and t-tau [468 pg/ml (275-698)] were decreased compared to Alzheimer's disease (P < 0.001, P = 0.001) and mild cognitive impairment due to Alzheimer's disease (P = 0.001, P = 0.07), but elevated compared to mild cognitive impairment and healthy controls (both P < 0.001). Multivariate modelling validated independent clinical association of cerebral amyloid angiopathy with older age [odds-ratio: 1.06, 95% confidence interval (1.02-1.10), P < 0.01], prior lobar intracerebral haemorrhage [14.00 (2.64-74.19), P < 0.01], prior ischaemic stroke [3.36 (1.58-7.11), P < 0.01], transient focal neurologic episodes (TFNEs) [4.19 (1.06-16.64), P = 0.04] and gait disturbance [2.82 (1.11-7.15), P = 0.03]. For cerebrospinal fluid-biomarkers per 1 pg/ml, both lower Aß40 [0.9999 (0.9998-1.0000), P < 0.01] and lower Aß42 levels [0.9989 (0.9980-0.9998), P = 0.01] provided an independent association with cerebral amyloid angiopathy controlled for all aforementioned clinical confounders. Both amyloid biomarkers showed good discrimination for diagnosis of cerebral amyloid angiopathy among adjusted receiver operating characteristic analyses (area under the receiver operating characteristic curves, Aß40: 0.80 (0.73-0.86), P < 0.001; Aß42: 0.81 (0.75-0.88), P < 0.001). Unsupervised Euclidian clustering of all cerebrospinal fluid-biomarker-profiles resulted in distinct segregation of cerebral amyloid angiopathy patients from all controls. Together, we demonstrate that a distinctive set of cerebrospinal fluid-biomarkers effectively differentiate cerebral amyloid angiopathy patients from patients with Alzheimer's disease, mild cognitive impairment with or without underlying Alzheimer's disease, and healthy controls. Integrating our findings into a multiparametric approach may facilitate diagnosing cerebral amyloid angiopathy, and may aid clinical decision-making, but warrants future prospective validation.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Christoph Lusse
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Mathias Linnerbauer
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Anne Mrochen
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Michael Knott
- Department of Neuroradiology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Timo Jan Oberstein
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Juan Manuel Maler
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Piotr Lewczuk
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
- Department of Neurodegeneration Diagnostics, Medical University of Bialystok, and Department of Biochemical Diagnostics, University Hospital of Bialystok, 15-090 Bialystok, Poland
| | - Veit Rothhammer
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Joji B Kuramatsu
- Correspondence to: Joji B. Kuramatsu, MD Department of Neurology, University Hospital Erlangen Schwabachanlage 6, 91054 Erlangen, Germany E-mail:
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10
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Kuhlenbäumer G, Jensen-Kondering U, Margraf NG. Letter for: Decreased cerebrospinal fluid Aβ 38, 40, 42, and 43 levels in sporadic and hereditary cerebral amyloid angiopathy. Ann Neurol 2023. [PMID: 37186313 DOI: 10.1002/ana.26671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/07/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Gregor Kuhlenbäumer
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Germany
| | - Ulf Jensen-Kondering
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübck, Germany
| | - Nils G Margraf
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Germany
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11
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Can novel CT-and MR-based neuroimaging biomarkers further improve the etiological diagnosis of lobar intra-cerebral hemorrhage? J Neurol 2023; 270:582-588. [PMID: 36307736 DOI: 10.1007/s00415-022-11434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/07/2023]
Abstract
Lobar hematomas represent around half of all supratentorial hemorrhages and have high mortality and morbidity. Their management depends on the underlying cause. Apart from local causes such as vascular malformation, which are rare and can usually be easily excluded thanks to imaging, the vast majority of lobar hematomas equally frequently result from either hypertensive arteriolopathy (HA) or cerebral amyloid angiopathy (CAA). Distinguishing between CAA and HA is important for prognostication (risk of recurrence nearly sevenfold higher in the former), for decision-making regarding, e.g., antithrombotic therapies (for other indications) and for clinical trials of new therapies. Currently, a non-invasive diagnosis of probable CAA can be made using the MR-based modified Boston criteria, which have excellent specificity but moderate sensitivity against histopathological reference, leading to the clinically largely irrelevant diagnosis of "possible CAA". Furthermore, the Boston criteria cannot be applied when both lobar and deep MRI hemorrhagic markers are present, a not uncommon situation. Here we propose to test whether new CT and MR-based imaging biomarkers, namely finger-like projections of the hematoma and adjacent subarachnoid hemorrhage on acute-stage CT or MRI, and remote punctate diffusion-weighted imaging ischemic lesions on acute or subacute-stage MRI, have the potential to improve the performance of the Boston criteria. Furthermore, we also propose to test whether clinical-radiological biomarkers may also allow a positive diagnosis of HA to be made in lobar hematomas, which, if feasible, would not only further reduce the prevalence of "possible CAA" but also permit a diagnosis of HA and/or CAA to be made in the presence of mixed deep and lobar MRI hemorrhagic markers.
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12
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Taggi V, Riera Romo M, Piquette-Miller M, Meyer zu Schwabedissen HE, Neuhoff S. Transporter Regulation in Critical Protective Barriers: Focus on Brain and Placenta. Pharmaceutics 2022; 14:pharmaceutics14071376. [PMID: 35890272 PMCID: PMC9319476 DOI: 10.3390/pharmaceutics14071376] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 01/06/2023] Open
Abstract
Drug transporters play an important role in the maintenance of chemical balance and homeostasis in different tissues. In addition to their physiological functions, they are crucial for the absorption, distribution, and elimination of many clinically important drugs, thereby impacting therapeutic efficacy and toxicity. Increasing evidence has demonstrated that infectious, metabolic, inflammatory, and neurodegenerative diseases alter the expression and function of drug transporters. However, the current knowledge on transporter regulation in critical protective barriers, such as the brain and placenta, is still limited and requires more research. For instance, while many studies have examined P-glycoprotein, it is evident that research on the regulation of highly expressed transporters in the blood–brain barrier and blood–placental barrier are lacking. The aim of this review is to summarize the currently available literature in order to better understand transporter regulation in these critical barriers.
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Affiliation(s)
- Valerio Taggi
- Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland; (V.T.); (H.E.M.z.S.)
| | - Mario Riera Romo
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada; (M.R.R.); (M.P.-M.)
| | - Micheline Piquette-Miller
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada; (M.R.R.); (M.P.-M.)
| | | | - Sibylle Neuhoff
- Certara UK Ltd., Simcyp Division, Sheffield S1 2BJ, UK
- Correspondence:
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