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Szalardy L, Fakan B, Maszlag-Torok R, Ferencz E, Reisz Z, Radics BL, Csizmadia S, Szpisjak L, Annus A, Zadori D, Kovacs GG, Klivenyi P. Identifying diagnostic and prognostic factors in cerebral amyloid angiopathy-related inflammation: A systematic analysis of published and seven new cases. Neuropathol Appl Neurobiol 2024; 50:e12946. [PMID: 38093468 DOI: 10.1111/nan.12946] [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: 11/19/2022] [Revised: 11/02/2023] [Accepted: 12/05/2023] [Indexed: 02/17/2024]
Abstract
AIMS Cerebral amyloid angiopathy (CAA)-related inflammation (CAA-RI) is a potentially reversible manifestation of CAA, histopathologically characterised by transmural and/or perivascular inflammatory infiltrates. We aimed to identify clinical, radiological and laboratory variables capable of improving or supporting the diagnosis of or predicting/influencing the prognosis of CAA-RI and to retrospectively evaluate different therapeutic approaches. METHODS We present clinical and neuroradiological observations in seven unpublished CAA-RI cases, including neuropathological findings in two definite cases. These cases were included in a systematic analysis of probable/definite CAA-RI cases published in the literature up to 31 December 2021. Descriptive and associative analyses were performed, including a set of clinical, radiological and laboratory variables to predict short-term, 6-month and 1-year outcomes and mortality, first on definite and second on an expanded probable/definite CAA-RI cohort. RESULTS Data on 205 definite and 100 probable cases were analysed. CAA-RI had a younger symptomatic onset than non-inflammatory CAA, without sex preference. Transmural histology was more likely to be associated with the co-localisation of microbleeds with confluent white matter hyperintensities on magnetic resonance imaging (MRI). Incorporating leptomeningeal enhancement and/or sulcal non-nulling on fluid-attenuated inversion recovery (FLAIR) enhanced the sensitivity of the criteria. Cerebrospinal fluid pleocytosis was associated with a decreased probability of clinical improvement and longer term positive outcomes. Future lobar haemorrhage was associated with adverse outcomes, including mortality. Immunosuppression was associated with short-term improvement, with less clear effects on long-term outcomes. The superiority of high-dose over low-dose corticosteroids was not established. CONCLUSIONS This is the largest retrospective associative analysis of published CAA-RI cases and the first to include an expanded probable/definite cohort to identify diagnostic/prognostic markers. We propose points for further crystallisation of the criteria and directions for future prospective studies.
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Affiliation(s)
- Levente Szalardy
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
- Department of Laboratory Medicine and Pathobiology and Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Bernadett Fakan
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Rita Maszlag-Torok
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Emil Ferencz
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Zita Reisz
- Institute of Pathology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
- Department of Clinical Neuropathology, King's College Hospital, London, UK
| | - Bence L Radics
- Institute of Pathology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | | | - Laszlo Szpisjak
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Adam Annus
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Denes Zadori
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Gabor G Kovacs
- Department of Laboratory Medicine and Pathobiology and Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
- Laboratory Medicine Program and Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Peter Klivenyi
- Department of Neurology, Albert Szent-Györgyi Medical School, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
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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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Fernandes L, Maguire M, Igra MS, Mavroudis I, Cosgrove J. Adult-onset leukoencephalopathy with calcifications and cysts. Pract Neurol 2023; 23:251-252. [PMID: 36697224 DOI: 10.1136/pn-2022-003634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Linford Fernandes
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Melissa Maguire
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mark S Igra
- Department of Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ioannis Mavroudis
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jeremy Cosgrove
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Theodorou A, Palaiodimou L, Malhotra K, Zompola C, Katsanos AH, Shoamanesh A, Boviatsis E, Dardiotis E, Spilioti M, Sacco S, Werring DJ, Cordonnier C, Alexandrov AV, Paraskevas GP, Tsivgoulis G. Clinical, Neuroimaging, and Genetic Markers in Cerebral Amyloid Angiopathy-Related Inflammation: A Systematic Review and Meta-Analysis. Stroke 2023; 54:178-188. [PMID: 36453271 DOI: 10.1161/strokeaha.122.040671] [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: 12/05/2022]
Abstract
BACKGROUND There are limited data regarding the prevalence of distinct clinical, neuroimaging and genetic markers among patients diagnosed with cerebral amyloid angiopathy-related inflammation (CAA-ri). We sought to determine the prevalence of clinical, radiological, genetic and cerebrospinal fluid biomarker findings in patients with CAA-ri. METHODS A systematic review and meta-analysis of published studies including patients with CAA-ri was conducted to determine the prevalence of clinical, neuroimaging, genetic and cerebrospinal fluid biomarker findings. Subgroup analyses were performed based on (1) prospective or retrospective study design and (2) CAA-ri diagnosis with or without available biopsy. We pooled the prevalence rates using random-effects models and assessed the heterogeneity using Cochran-Q and I2-statistics. RESULTS We identified 4 prospective and 17 retrospective cohort studies comprising 378 patients with CAA-ri (mean age, 71.5 years; women, 52%). The pooled prevalence rates were as follows: cognitive decline at presentation 70% ([95% CI, 54%-84%]; I2=82%), focal neurological deficits 55% ([95% CI, 40%-70%]; I2=82%), encephalopathy 54% ([95% CI, 39%-68%]; I2=43%), seizures 37% ([95% CI, 27%-49%]; I2=65%), headache 31% ([95% CI, 22%-42%]; I2=58%), T2/fluid-attenuated inversion recovery-hyperintense white matter lesions 98% ([95% CI, 93%-100%]; I2=44%), lobar cerebral microbleeds 96% ([95% CI, 92%-99%]; I2=25%), gadolinium enhancing lesions 54% ([95% CI, 42%-66%]; I2=62%), cortical superficial siderosis 51% ([95% CI, 34%-68%]; I2=77%) and lobar macrohemorrhage 40% ([95% CI, 11%-73%]; I2=88%). The prevalence rate of the ApoE (Apolipoprotein E) ε4/ε4 genotype was 34% ([95% CI, 17%-53%]; I2=76%). Subgroup analyses demonstrated no differences in these prevalence rates based on study design and diagnostic strategy. CONCLUSIONS Cognitive decline was the most common clinical feature. Hyperintense T2/fluid-attenuated inversion recovery white matter lesions and lobar cerebral microbleeds were by far the most prevalent neuroimaging findings. Thirty-four percent of patients with CAA-ri have homozygous ApoE ε4/ε4 genotype and scarce data exist regarding the cerebrospinal fluid biomarkers and its significance in these patients.
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Affiliation(s)
- Aikaterini Theodorou
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Lina Palaiodimou
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.)
| | - Christina Zompola
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Efstathios Boviatsis
- Department of Neurosurgery (E.B.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Efthimios Dardiotis
- Neurology Department, University Hospital of Larissa, University of Thessaly, Greece (E.D.)
| | - Martha Spilioti
- First Department of Neurology, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece (M.S.)
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio, Italy (S.S.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, France (C.C.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
| | - George P Paraskevas
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology (A.T., L.P., C.Z., G.P.P., G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
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Cerebral Amyloid Angiopathy-Related Inflammation: A Single-Center Experience and a Literature Review. J Clin Med 2022; 11:jcm11226731. [PMID: 36431207 PMCID: PMC9692654 DOI: 10.3390/jcm11226731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Limited data exist regarding the prevalence of clinical, neuroimaging, and genetic markers among patients diagnosed with Cerebral Amyloid Angiopathy−related inflammation (CAA-ri). We sought to determine these characteristics in patients diagnosed in our center and to summarize available literature published either as single-case reports or small case series (<5 patients). Methods: We reported our single-center experience of patients diagnosed with CAA-ri according to international criteria during a seven-year period (2015−2022), and we abstracted data from 90 previously published cases. Results: Seven patients (43% women, mean age 70 ± 13 years) were diagnosed with CAA-ri in our center. The most common symptom at presentation was focal neurological dysfunction (71%), and the most prevalent radiological finding was the presence of T2/FLAIR white matter hyperintensities (100%). All patients were treated with corticosteroids and had a favorable functional outcome. Among 90 previously published CAA-ri cases (51% women, mean age 70 ± 9 years), focal neurological dysfunction was the most common symptom (76%), followed by a cognitive decline (46%) and headache (34%). The most prevalent neuroimaging findings were cerebral microbleeds (85%), asymmetric T2/FLAIR white matter hyperintensities (81%), and gadolinium-enhancing T1-lesions (37%). Genetic testing for the Apolipoprotein-E gene was available in 27 cases; 59% carried the APOE ε4/ε4 genotype. The majority of the published CAA-ri cases (78%) received corticosteroid monotherapy, while 17 patients (19%) were treated with additional immunosuppressive treatment. Favorable functional outcome following treatment was documented in 70% of patients. Conclusion: Improving the vigilance of clinicians regarding the early recognition and accurate diagnosis of CAA-ri is crucial for swift therapy initiation, which may result in improved functional outcomes.
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Chen D, Roytman M, Kirou KA, Navi BB, Schweitzer AD. A case of inflammatory cerebral amyloid angiopathy after ischemic stroke - a potential risk factor related to blood-brain barrier disruption. Clin Imaging 2021; 82:161-165. [PMID: 34847499 DOI: 10.1016/j.clinimag.2021.11.007] [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: 08/23/2021] [Revised: 10/23/2021] [Accepted: 11/08/2021] [Indexed: 12/26/2022]
Abstract
Cerebral Amyloid Angiopathy (CAA) is a cerebrovascular disease prevalent in elderly patients and strongly associated with cognitive decline and intracranial hemorrhage. Inflammatory forms of CAA (CAA-Related Inflammation i.e. CAA-ri and Amyloid-Beta Related Angiitis i.e. ABRA) are responsible for rapid neurocognitive decline, but are highly responsive to corticosteroid treatment. We present a patient with history of CAA who developed probable CAA-ri/ABRA three months after an acute ischemic stroke. We review the literature and imaging criteria for CAA-ri/ABRA, and propose further research for any association between these entities and blood-brain barrier disruption in the setting of ischemia.
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Affiliation(s)
- Dora Chen
- Weill Cornell Medicine Medical College, United States of America
| | - Michelle Roytman
- Department of Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, United States of America
| | - Kyriakos A Kirou
- Department of Rheumatology, Hospital for Special Surgery/NewYork-Presbyterian Hospital/Weill Cornell Medicine, United States of America
| | - Babak B Navi
- Department of Neurology and the Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, United States of America
| | - Andrew D Schweitzer
- Department of Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, United States of America.
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Voicu IP, Tagliati C, Sciamanna S, Lanni G. Cerebral amyloid angiopathy-related inflammation: a rare disease that needs to be diagnosed. BMJ Case Rep 2021; 14:14/3/e242057. [PMID: 33664048 PMCID: PMC7934777 DOI: 10.1136/bcr-2021-242057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ioan Paul Voicu
- Department of Services, Radiology and MRI Unit, “G. Mazzini” Hospital, Teramo, Italy, ASL 4 Teramo, Teramo, Abruzzo, Italy
| | - Corrado Tagliati
- Department of Services, Radiology Unit, "S. Liberatore" Hospital, Atri, Italy, ASL 4 Teramo, Teramo, Abruzzo, Italy
| | - Samanta Sciamanna
- Department of medicine, Neurology Unit, “G. Mazzini” Hospital, Teramo, Italy, ASL 4 Teramo, Teramo, Abruzzo, Italy
| | - Giuseppe Lanni
- Department of Services, Radiology Unit, “S. Liberatore” Hospital, Atri, Italy, ASL 4 Teramo, Teramo, Abruzzo, Italy
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