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Munsterman D, Falcione S, Long R, Boghozian R, Joy T, Camicioli R, Smith EE, Jickling GC. Cerebral amyloid angiopathy and the immune system. Alzheimers Dement 2024. [PMID: 38881491 DOI: 10.1002/alz.13826] [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: 01/08/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 06/18/2024]
Abstract
Cerebral amyloid angiopathy (CAA) is characterized by the accumulation of amyloid protein in the walls of cerebral blood vessels. This deposition of amyloid causes damage to the cerebral vasculature, resulting in blood-brain barrier disruption, cerebral hemorrhage, cognitive decline, and dementia. The role of the immune system in CAA is complex and not fully understood. While the immune system has a clear role in the rare inflammatory variants of CAA (CAA related inflammation and Abeta related angiitis), the more common variants of CAA also have immune system involvement. In a protective role, immune cells may facilitate the clearance of beta-amyloid from the cerebral vasculature. The immune system can also contribute to CAA pathology, promoting vascular injury, blood-brain barrier breakdown, inflammation, and progression of CAA. In this review, we summarize the role of the immune system in CAA, including the potential of immune based treatment strategies to slow vascular disease in CAA and associated cognitive impairment, white matter disease progression, and reduce the risk of cerebral hemorrhage. HIGHLIGHTS: The immune system has a role in cerebral amyloid angiopathy (CAA) which is summarized in this review. There is an inflammatory response to beta-amyloid that may contribute to brain injury and cognitive impairment. Immune cells may facilitate the clearance of beta-amyloid from the cerebral vasculature. Improved understanding of the immune system in CAA may afford novel treatment to improve outcomes in patients with CAA.
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Affiliation(s)
| | - Sarina Falcione
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Rebecca Long
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Roobina Boghozian
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Twinkle Joy
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Camicioli
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Eric E Smith
- Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Glen C Jickling
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
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de Souza A, Tasker K. Inflammatory Cerebral Amyloid Angiopathy: A Broad Clinical Spectrum. J Clin Neurol 2023; 19:230-241. [PMID: 37151140 PMCID: PMC10169922 DOI: 10.3988/jcn.2022.0493] [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: 12/26/2022] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a common central nervous system (CNS) vasculopathy, which in some cases is associated with subacute encephalopathy, seizures, headaches, or strokes due to vascular inflammation directed against vascular amyloid accumulation. The pathological subtypes of inflammatory CAA include CAA-related inflammation (CAAri) with mostly perivascular lymphocytic infiltrates, or amyloid-beta (Aβ)-related angiitis (ABRA) with transmural granulomatous inflammation. CAAri and ABRA probably represent part of the spectrum of CNS vasculopathies, intermediate between CAA and primary CNS vasculitis, and they are closely related to Aβ-related imaging abnormalities and other manifestations of an inflammatory response directed against Aβ in the leptomeninges and cerebral parenchyma. As treatment strategies in Alzheimer's disease shift toward potentially effective antiamyloid immunotherapy, the incidence rate of inflammatory CAA (which is probably an underrecognized condition) is likely to increase. Its clinical features are varied and include subacute encephalopathy, behavioral symptoms, headaches, seizures, and focal neurological deficits, which necessitate a high degree of suspicion for this disorder that often responds to treatment. The recent definition of the typical clinical and radiological syndrome has increased its recognition and may eliminate the need for invasive histological sampling in at least some affected patients. Here we review the pathophysiology, clinical spectrum, and approach to diagnosis, and discuss illustrative cases that highlight the wide range of clinical presentations.
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Affiliation(s)
- Aaron de Souza
- Department of Medicine, Launceston General Hospital, Launceston, Australia
- Faculty of Medicine, Launceston Clinical School, University of Tasmania, Launceston, Australia.
| | - Kate Tasker
- Department of Medicine, Launceston General Hospital, Launceston, Australia
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Chwalisz BK. Cerebral amyloid angiopathy and related inflammatory disorders. J Neurol Sci 2021; 424:117425. [PMID: 33840507 DOI: 10.1016/j.jns.2021.117425] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/27/2020] [Accepted: 03/24/2021] [Indexed: 11/19/2022]
Abstract
Inflammatory cerebral amyloid angiopathy is a largely reversible inflammatory vasculopathy that develops in an acute or subacute fashion in reaction to amyloid protein deposition in the central nervous system blood vessels. There are two recognized pathologically characterized variants: cerebral amyloid angiopathy-related inflammation (CAAri) and A beta-related angiitis (ABRA). Both variants produce a clinical picture that resembles primary angiitis of the CNS but is distinguished by a characteristic radiologic appearance. Although originally defined as a clinicopathologic diagnosis, it can now often be diagnosed based on clinicoradiologic criteria, though confirmation with brain and meningeal biopsy is still required in some cases. This disorder typically responds to steroids but addition of other immune suppressants may be needed in some cases to control the disease.
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Affiliation(s)
- B K Chwalisz
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, 15 Parkman Street, Suite 835, Boston, MA 02114, USA; Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA.
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Corovic A, Kelly S, Markus HS. Cerebral amyloid angiopathy associated with inflammation: A systematic review of clinical and imaging features and outcome. Int J Stroke 2017; 13:257-267. [DOI: 10.1177/1747493017741569] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Cerebral amyloid angiopathy associated with inflammation is an increasingly recognized condition, characterized by an inflammatory response to the vascular deposits of β-amyloid within the brain that are the hallmark of cerebral amyloid angiopathy. Two main patterns of this inflammatory response have been identified to date: one involving a perivascular inflammatory cell infiltrate (cerebral amyloid angiopathy-related inflammation); the other a transmural vasculitic process (A-beta related angiitis). Unlike cerebral amyloid angiopathy itself, which predisposes to intracerebral hemorrhage and has no known treatment, cerebral amyloid angiopathy associated with inflammation typically presents in diverse ways and diagnosis may be challenging and delayed. Aims We sought to summarize the clinical features, imaging appearances and available data on outcome and treatment responses, using information derived from a systematic review of pathologically proven cases of cerebral amyloid angiopathy associated with inflammation. Summary of review We identified 213 distinct pathologically proven cases of cerebral amyloid angiopathy-related inflammation/A-beta related angiitis, from 104 publications. The clinical presentation, imaging features, pathology, treatment, and outcomes of cerebral amyloid angiopathy associated with inflammation are described. Conclusions Cerebral amyloid angiopathy associated with inflammation is an important and increasingly recognized clinical condition, which affects the older patient population and presents most commonly with cognitive decline, seizures, and headaches. Future research is required to develop and validate diagnostic criteria and determine optimum treatment strategies.
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Affiliation(s)
- Andrej Corovic
- Department of Stroke Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Siobhan Kelly
- Department of Stroke Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Hugh S Markus
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
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Chu S, Xu F, Su Y, Chen H, Cheng X. Cerebral Amyloid Angiopathy (CAA)-Related Inflammation: Comparison of Inflammatory CAA and Amyloid-β-Related Angiitis. J Alzheimers Dis 2016; 51:525-32. [PMID: 26890776 DOI: 10.3233/jad-151036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Shuguang Chu
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Feijia Xu
- Department of Radiology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| | - Ya Su
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Hong Chen
- Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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Sun LI, Zhu L, Zhao T, Wang D, Ma D, Zhang R, Fang S. A rare case of tumor-mimicking primary angiitis of the central nervous system. Mol Clin Oncol 2016; 4:827-829. [PMID: 27123289 DOI: 10.3892/mco.2016.784] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/04/2016] [Indexed: 11/06/2022] Open
Abstract
Primary angiitis of the central nervous system (PACNS) is a rare, but severe vascular disease. The present study reports the case of a 42-year-old male who developed PACNS. Magnetic resonance imaging (MRI) scans initially led to a misleading diagnosis of malignant glioma, and surgery was performed. The mass was resected, and a pathological examination confirmed a cerebral vasculitis. Single therapy with high doses of steroid did not improve the patient's condition, while a subsequent lesion appeared on the opposite side one year later. Combined therapy with methylprednisone and cyclophosphamide resulted in a great improvement for the patient. No relapse occurred during one year's follow-up. Although a tumor-mimicking PACNS has no established imaging features, a diagnosis of tumor-mimicking PACNS should be suspected when the MRI reveals inappropriate presentations of a tumor. Greater awareness of this potential manifestation of PACNS may facilitate more prompt diagnosis and treatment.
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Affiliation(s)
- L I Sun
- Department of Neurology, The First Teaching Hospital of The Jilin University, Changchun, Jilin 130021, P.R. China
| | - Lijun Zhu
- Department of Neurology, The Third Teaching Hospital of The Jilin University, Changchun, Jilin 130033, P.R. China
| | - Teng Zhao
- Department of Neurology, The First Teaching Hospital of The Jilin University, Changchun, Jilin 130021, P.R. China
| | - Dayan Wang
- Qian Wei Hospital of Jilin Province, Changchun, Jilin 130031, P.R. China
| | - Dihui Ma
- Department of Neurology, The First Teaching Hospital of The Jilin University, Changchun, Jilin 130021, P.R. China
| | - Rensheng Zhang
- Department of Neurology, The First Teaching Hospital of The Jilin University, Changchun, Jilin 130021, P.R. China
| | - Shaokuan Fang
- Department of Neurology, The First Teaching Hospital of The Jilin University, Changchun, Jilin 130021, P.R. China
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Castro Caldas A, Silva C, Albuquerque L, Pimentel J, Silva V, Ferro JM. Cerebral Amyloid Angiopathy Associated with Inflammation: Report of 3 Cases and Systematic Review. J Stroke Cerebrovasc Dis 2015; 24:2039-48. [PMID: 26163888 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 03/20/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Cerebral amyloid angiopathy associated with inflammatory process (CAA-I) is a rare potentially treatable encephalopathy, characterized by an inflammatory response to vascular deposits of β-amyloid. We aimed to describe 3 clinical cases and perform a systematic review of all neuropathologically proved CAA-I case reports to describe its clinical and pathologic features and outcome under different treatments. METHODS We searched PubMed and Cochrane Library and screened references of included studies and review articles for additional citations. Outcome was classified at the last available follow-up by the modified Rankin Scale (mRS). RESULTS A total of 67 publications, reporting on 155 patients, were included. Mean age was 66.9 years, and 53.5% were men. The most common clinical presentation was cognitive dysfunction (48.0%) followed by headaches (38.7%), seizures (36.7%), and pyramidal signs (20.0%). Perivascular and vasculitic inflammation with granuloma was the most common pathologic pattern (27.5%). Eighty-six percent were treated with corticosteroids and 33.9% with cyclophosphamide. Forty-two percent regained independence (mRS score 0-2), whereas 20.5% were left with a severe handicap (mRS score 3-5) and 37.5% died. There were no statistically significant differences in outcome between patients treated with therapy with corticosteroids alone comparing with those treated with combination corticosteroids with cytostatic agents. CONCLUSIONS The most common clinical manifestation of CAA-I was cognitive dysfunction. The functional outcome was unfavorable in the majority of the patients, with death or severe disability in almost two third of the cases, despite treatment. No differences in outcome could be detected between patients treated with corticosteroids versus patients treated with cytostatics, combined with corticosteroids.
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Affiliation(s)
- Ana Castro Caldas
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.
| | - Cristiana Silva
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Luísa Albuquerque
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal
| | - José Pimentel
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal; Laboratory of Neuropathology, Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal
| | - Vanessa Silva
- Serviço de Neurologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - José Manuel Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Faculdade de Medicina de Lisboa, University of Lisbon, Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal
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Syndrome de vasoconstriction cérébrale segmentale réversible ou angéite primitive du Systeme nerveux central? Can J Neurol Sci 2014. [DOI: 10.1017/s0317167100007381] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background:Reversible Cerebral Vasoconstriction Syndrome (RCVS) may present as thunderclap headache (TCH), accompanied by reversible cerebral vasospasm and focal neurological deficits, often without a clear precipitant. RCVS may be mistaken for Primary Angiitis of the Central Nervous System (PACNS) due to the presence of similar angiographic features of segmental narrowing of cerebral arteries. We discuss the clinical features of a young female migraine patient who developed TCH and was found to have RCVS following initial treatment with corticosteroids for PACNS, in the context of a systematic review of the available medical literature.Methods:A Medline™ search was performed to identify all case reports since 1966 describing RCVS and PACNS that provide sufficient clinical detail to permit diagnostic classification according to published criteria. RCVS included case studies in which there was angiographic or transcranial Doppler ultrasound evidence of near-to-complete resolution of cerebral vasoconstriction in the absence of a well-recognized secondary cause. PACNS included reports of histologically confirmed PACNS either through biopsy or necropsy.Results:Reversible Cerebral Vasoconstriction Syndrome occurs primarily in females and is characterized by sudden, severe headache at onset, normal CSF analysis, vasoconstriction involving the Circle of Willis and its immediate branches, and angiographic or TCD ultrasound evidence of near-to-complete vasospastic resolution within 1-4 weeks. It occurs typically in the context of vasoconstrictive drug use, the peripartum period, bathing, and physical exertion.Conclusion:Initial and follow-up (within 4 weeks) non-invasive angiographic studies are indicated in patients who present with TCH or who have clinical presentations that could be consistent with RCVS or PACNS in the absence of a well-recognized secondary cause, such as subarachnoid haemorrhage. Early reversibility of cerebral vasospasm is the key neuroradiological feature that supports the clinical diagnosis of RCVS.
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Danve A, Grafe M, Deodhar A. Amyloid Beta-Related Angiitis—A Case Report and Comprehensive Review of Literature of 94 Cases. Semin Arthritis Rheum 2014; 44:86-92. [DOI: 10.1016/j.semarthrit.2014.02.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/27/2014] [Accepted: 02/07/2014] [Indexed: 11/30/2022]
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Agyare EK, Jaruszewski KM, Curran GL, Rosenberg JT, Grant SC, Lowe VJ, Ramakrishnan S, Paravastu AK, Poduslo JF, Kandimalla KK. Engineering theranostic nanovehicles capable of targeting cerebrovascular amyloid deposits. J Control Release 2014; 185:121-9. [PMID: 24735640 DOI: 10.1016/j.jconrel.2014.04.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/21/2014] [Accepted: 04/04/2014] [Indexed: 11/26/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is characterized by the deposition of amyloid beta (Aβ) proteins within the walls of the cerebral vasculature with subsequent aggressive vascular inflammation leading to recurrent hemorrhagic strokes. The objective of the study was to develop theranostic nanovehicles (TNVs) capable of a) targeting cerebrovascular amyloid; b) providing magnetic resonance imaging (MRI) contrast for the early detection of CAA; and c) treating cerebrovascular inflammation resulting from CAA. The TNVs comprised of a polymeric nanocore made from Magnevist (MRI contrast agent) conjugated chitosan. The nanocore was also loaded with cyclophosphamide (CYC), an immunosuppressant shown to reduce the cerebrovascular inflammation in CAA. Putrescine modified F(ab')2 fragment of anti-amyloid antibody, IgG4.1 (pF(ab')24.1) was conjugated to the surface of the nanocore to target cerebrovascular amyloid. The average size of the control chitosan nanoparticles (conjugated with albumin and are devoid of Magnevist, CYC, and pF(ab')24.1) was 164±1.2 nm and that of the TNVs was 239±4.1 nm. The zeta potential values of the CCNs and TNVs were 21.6±1.7 mV and 11.9±0.5 mV, respectively. The leakage of Magnevist from the TNVs was a modest 0.2% over 4 days, and the CYC release from the TNVs followed Higuchi's model that describes sustained drug release from polymeric matrices. The studies conducted in polarized human microvascular endothelial cell monolayers (hCMEC/D3) in vitro as well as in mice in vivo have demonstrated the ability of TNVs to target cerebrovascular amyloid. In addition, the TNVs provided contrast for imaging cerebrovascular amyloid using MRI and single photon emission computed tomography. Moreover, the TNVs were shown to reduce pro-inflammatory cytokine production by the Aβ challenged blood brain barrier (BBB) endothelium more effectively than the cyclophosphamide alone.
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Affiliation(s)
- Edward K Agyare
- Division of Basic Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, 1520 S. MLK BLVD, Tallahassee 32307, USA
| | - Kristen M Jaruszewski
- Department of Pharmaceutics and Brain Barriers Research Center, University of Minnesota, 308 Harvard St. SE, Room 9-149A WDH, Minneapolis 55455, USA; Molecular Neurobiology Laboratory, Departments of Neurology, Neuroscience, and Biochemistry/Molecular Biology, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester 55905, USA
| | - Geoffry L Curran
- Molecular Neurobiology Laboratory, Departments of Neurology, Neuroscience, and Biochemistry/Molecular Biology, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester 55905, USA
| | - Jens T Rosenberg
- The Florida State University and National High Magnetic Field Laboratory, 1800 East Paul Dirac Drive, Tallahassee 32310, USA
| | - Samuel C Grant
- The Florida State University and National High Magnetic Field Laboratory, 1800 East Paul Dirac Drive, Tallahassee 32310, USA; Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, 2525 Pottsdamer Street, Tallahassee 32310, USA
| | - Val J Lowe
- Nuclear Medicine, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester 55905, USA
| | - Subramanian Ramakrishnan
- Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, 2525 Pottsdamer Street, Tallahassee 32310, USA
| | - Anant K Paravastu
- The Florida State University and National High Magnetic Field Laboratory, 1800 East Paul Dirac Drive, Tallahassee 32310, USA; Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, 2525 Pottsdamer Street, Tallahassee 32310, USA
| | - Joseph F Poduslo
- Molecular Neurobiology Laboratory, Departments of Neurology, Neuroscience, and Biochemistry/Molecular Biology, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester 55905, USA
| | - Karunya K Kandimalla
- Department of Pharmaceutics and Brain Barriers Research Center, University of Minnesota, 308 Harvard St. SE, Room 9-149A WDH, Minneapolis 55455, USA; Molecular Neurobiology Laboratory, Departments of Neurology, Neuroscience, and Biochemistry/Molecular Biology, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester 55905, USA.
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Hagiwara Y, Yanagisawa T, Atsumi C, Maki F, Shimizu T, Hasegawa Y. [A case report of cerebral amyloid angiopathy-related inflammation treated with cyclophosphamide]. Rinsho Shinkeigaku 2014; 54:46-51. [PMID: 24429648 DOI: 10.5692/clinicalneurol.54.46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 78-year-old woman was admitted to another hospital with progressive cognitive dysfunction and right hemiparesis. Magnetic resonance imaging (MRI) of the brain revealed a high-intensity area in bilateral frontal lobes on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR). Brain biopsy revealed no significant findings. She was transferred to our hospital for further examination. Although the etiology of the white matter lesion was not specified, the lesion and symptoms improved with steroid pulse therapy. Three months later, disturbance of consciousness and right hemiparesis worsened again, and the white matter lesion was expanded on MRI. Steroid pulse therapy was again performed, but her condition gradually deteriorated and akinetic mutism developed. T2-based imaging showed microbleeds and analysis of the apolipoprotein E (ApoE) genotype showed ε4/ε4; therefore, cerebral amyloid angiopathy-related inflammation was diagnosed. Two cycles of cyclophosphamide pulse therapy were performed, resulting in improvement of the white matter lesion, disorder of consciousness, and hemiparesis after the first cycle. The patient was discharged from our hospital in an ambulatory state. Steroid therapy for cerebral amyloid angiopathy-related inflammation is relatively well-known in Japan, but cyclophosphamide therapy appears useful for steroid-resistant amyloid angiopathy-related inflammation in the early stage of the disease.
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Affiliation(s)
- Yuta Hagiwara
- Department of Internal Medicine, Division of Neurology, St. Marianna University School of Medicine
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Sakaguchi H, Ueda A, Kosaka T, Yamashita S, Kimura E, Yamashita T, Maeda Y, Hirano T, Uchino M. Cerebral amyloid angiopathy-related inflammation presenting with steroid-responsive higher brain dysfunction: case report and review of the literature. J Neuroinflammation 2011; 8:116. [PMID: 21914214 PMCID: PMC3185269 DOI: 10.1186/1742-2094-8-116] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 09/14/2011] [Indexed: 11/10/2022] Open
Abstract
A 56-year-old man noticed discomfort in his left lower limb, followed by convulsion and numbness in the same area. Magnetic resonance imaging (MRI) showed white matter lesions in the right parietal lobe accompanied by leptomeningeal or leptomeningeal and cortical post-contrast enhancement along the parietal sulci. The patient also exhibited higher brain dysfunction corresponding with the lesions on MRI. Histological pathology disclosed β-amyloid in the blood vessels and perivascular inflammation, which highlights the diagnosis of cerebral amyloid angiopathy (CAA)-related inflammation. Pulse steroid therapy was so effective that clinical and radiological findings immediately improved.CAA-related inflammation is a rare disease, defined by the deposition of amyloid proteins within the leptomeningeal and cortical arteries associated with vasculitis or perivasculitis. Here we report a patient with CAA-related inflammation who showed higher brain dysfunction that improved with steroid therapy. In cases with atypical radiological lesions like our case, cerebral biopsy with histological confirmation remains necessary for an accurate diagnosis.
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Affiliation(s)
- Hideya Sakaguchi
- Department of Neurology, Faculty of Life Sciences, Kumamoto University 1-1-1 Honjo, Kumamoto 860-0811, Japan.
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You G, Yan W, Zhang W, Li S, Li G, Jiang T. Isolated angiitis of the central nervous system with tumor-like lesion, mimicking brain malignant glioma: a case report and review of the literature. World J Surg Oncol 2011; 9:97. [PMID: 21867556 PMCID: PMC3178486 DOI: 10.1186/1477-7819-9-97] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 08/26/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isolated angiitis of the central nervous system (IACNS) is a rare but severe vascular disease, which could present like an isolated inflammatory lesion on magnetic resonance imaging (MRI). To date, only a few such cases with tumor-like IACNS have been reported. CASE PRESENTATION A 35-year-old woman presented with headache and left-sided weakness. MRI scans initially mislead us to a diagnosis of glioblastoma (GBM). Surgery was performed. The mass was sub-totally resected. Pathological examination confirmed a cerebral vasculitis. Radiological features, such as disproportionate mass effect, striped hemorrhage and abnormal enhancement of adjacent vessels, could be helpful to distinguish a tumor-like IACNS from a GBM. Single therapy with high doses of steroid did not improve the patient's condition. Combined therapy with prednisolone and cyclophosphamide showed great benefit to the patient. No relapse occurred during the period of 18 months follow-up. CONCLUSIONS Although a tumor-like IACNS has no established imaging features, a diagnosis of tumor-like IACNS should be suspected when MRI shows inappropriate presentations of a tumor. Greater awareness of this potential manifestation of IACNS may facilitate more prompt diagnosis and treatment.
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Affiliation(s)
- Gan You
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Cerebral amyloid angiopathy related vasculitis: successful treatment with azathioprine. J Neurol 2010; 257:2103-5. [DOI: 10.1007/s00415-010-5665-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 07/04/2010] [Accepted: 07/05/2010] [Indexed: 10/19/2022]
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Steroid responsive encephalopathy in cerebral amyloid angiopathy: a case report and review of evidence for immunosuppressive treatment. J Neuroinflammation 2010; 7:18. [PMID: 20214781 PMCID: PMC2846904 DOI: 10.1186/1742-2094-7-18] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 03/09/2010] [Indexed: 11/10/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a common but often asymptomatic disease, characterized by deposition of amyloid in cerebral blood vessels. We describe the successful treatment of CAA encephalopathy with dexamethasone in a patient with CAA-related inflammation causing subacute progressive encephalopathy and seizures, which is an increasingly recognized subtype of CAA. The two pathological subtypes of CAA-related inflammation are described and a review of the literature is performed concerning immunosuppressive treatment of CAA-related inflammation with special attention to its pathological subtypes. Immunosuppressive therapy appears to be an appropriate treatment for CAA encephalopathy.
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Kraemer M, Berlit P. Primary central nervous system vasculitis: clinical experiences with 21 new European cases. Rheumatol Int 2009; 31:463-72. [DOI: 10.1007/s00296-009-1312-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 11/29/2009] [Indexed: 11/30/2022]
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17
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Qu SB, Khan S, Liu H. Primary central nervous system vasculitis mimicking brain tumour: case report and literature review. Rheumatol Int 2009; 30:127-34. [DOI: 10.1007/s00296-009-0914-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 03/25/2009] [Indexed: 12/01/2022]
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Herath SS, Law DB, Stride PJO, Heazlewood VJ, Gaffney LS. A case of primary cerebral vasculitis. Med J Aust 2008; 188:547-9. [DOI: 10.5694/j.1326-5377.2008.tb01779.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 02/07/2008] [Indexed: 11/17/2022]
Affiliation(s)
| | - Dayna B Law
- Department of Medicine, Redcliffe Hospital, Redcliffe, QLD
| | | | | | - Luke S Gaffney
- Department of Medicine, Redcliffe Hospital, Redcliffe, QLD
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Marotti JD, Savitz SI, Kim WK, Williams K, Caplan LR, Joseph JT. Scientific correspondence. Neuropathol Appl Neurobiol 2007; 33:475-9. [PMID: 17573809 DOI: 10.1111/j.1365-2990.2007.00843.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Cabrejo L, Chassagne P, Doucet J, Laquerrière A, Puech N, Hannequin D. Angiopathie amyloïde cérébrale sporadique. Rev Neurol (Paris) 2006; 162:1059-67. [PMID: 17086142 DOI: 10.1016/s0035-3787(06)75118-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Sporadic cerebral amyloid angiopathy (CAA) is a microangiopathy identified by neuropathological examination in more than 30 percent of patients over 85 years of age. STATE OF ART Boston criteria for diagnosis of CAA--related hemorrhage are as follows: "definite CAA", "Probable CAA with supporting pathology", "Probable CAA" and "Possible CAA". Clinical manifestations of CAA are either lobar, cortical, corticosubcortical or cerebellar hemorrhages associated with progressive dementia. Dementia, corresponding either to Alzheimer disease, vascular or mixed dementia, precedes hemorrhages in 25 to 40 percent of cases. Brain MRI can demonstrate microbleeding. PERSPECTIVES This review compares data regarding CAA prevalence, intracranial hemorrhages, and their risk factors in old patients. Diagnosis and preventive strategies are discussed. It would be useful to identify those affected by CAA among elderly demented patients with atrial fibrillation requiring anticoagulation therapy. CONCLUSIONS CAA is suspected in the presence of recurrent lobar or cerebellar hemorrhages, and moreover if associated with pre-existing dementia. In elderly demented patients, MRI criteria to detect CAA should be considered in order to prevent hemorrhage risk, particularly after anticoagulation therapy.
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Affiliation(s)
- L Cabrejo
- Département de Neurologie, CHU de Rouen.
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21
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Yamazaki-Nakashimada M, Zaltzman-Girshevich S, Garcia de la Puente S, De Leon-Bojorge B, Espinosa-Padilla S, Saez-de-Ocariz M, Carrasco-Daza D, Hernandez-Bautista V, Pérez-Fernandez L, Espinosa-Rosales F. Hyper-IgE syndrome and autoimmunity in Mexican children. Pediatr Nephrol 2006; 21:1200-5. [PMID: 16791602 DOI: 10.1007/s00467-006-0178-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 03/28/2006] [Accepted: 03/31/2006] [Indexed: 11/30/2022]
Abstract
Hyper-IgE syndrome (HIES) is a primary immunodeficiency characterized by recurrent skin abscesses, recurrent pneumonia with pneumatocele formation, eczema, eosinophilia, and elevated levels of serum IgE. Patients with the autosomal recessive (AR) form of HIES appear to be prone to developing autoimmune diseases. We present two cases of HIES with autoimmune complications; one case was a product of a consanguineous marriage, the other one was a sporadic case. The first patient presented with recurrent episodes of erythema nodosum, warts, bronchiolitis obliterans and thrombocytopenia. The second patient developed glomerulonephritis resulting in endstage renal failure. She later developed malar rash, oral ulcers, cerebral infarcts with vasculitis and positive ANA, anti-dsDNA, and antiphospholipid antibodies. We discuss the dilemma in treating patients who present with both primary immunodeficiency and autoimmunity.
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Affiliation(s)
- Marco Yamazaki-Nakashimada
- Department of Clinical Immunology, Instituto Nacional de Pediatría, Insurgentes Sur 3700-C, Col. Insurgentes Cuicuilco, Mexico City, Mexico.
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22
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Wong SH, Robbins PD, Knuckey NW, Kermode AG. Cerebral amyloid angiopathy presenting with vasculitic pathology. J Clin Neurosci 2006; 13:291-4. [PMID: 16439133 DOI: 10.1016/j.jocn.2005.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 03/22/2005] [Indexed: 11/18/2022]
Abstract
We present an elderly patient with an unusual extensive multifocal central nervous system mass lesion, with dramatic imaging changes but only minor disturbance of cerebral function. Cerebral biopsy revealed an unexpected finding of severe cerebral amyloid angiopathy with secondary florid vasculitic appearances, which is a very rare but recognised association. Immunosuppression has produced significant sustained clinical and radiological remission.
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Affiliation(s)
- S H Wong
- Department of Neurology and Clinical Neurophysiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia 6009, Australia
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24
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Tamargo RJ, Connolly ES, McKhann GM, Khandji A, Chang Y, Libien J, Adams D. Clinicopathological review: primary angiitis of the central nervous system in association with cerebral amyloid angiopathy. Neurosurgery 2003; 53:136-43; discussion 143. [PMID: 12823882 DOI: 10.1227/01.neu.0000068864.20655.31] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2002] [Accepted: 02/12/2003] [Indexed: 11/19/2022] Open
Affiliation(s)
- Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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25
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Schwab P, Lidov HGW, Schwartz RB, Anderson RJ. Cerebral amyloid angiopathy associated with primary angiitis of the central nervous system: report of 2 cases and review of the literature. ARTHRITIS AND RHEUMATISM 2003; 49:421-7. [PMID: 12794799 DOI: 10.1002/art.11049] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pascale Schwab
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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26
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Oide T, Tokuda T, Takei YI, Takahashi H, Ito K, Ikeda SI. Serial CT and MRI findings in a patient with isolated angiitis of the central nervous system associated with cerebral amyloid angiopathy. Amyloid 2002; 9:256-62. [PMID: 12557755 DOI: 10.3109/13506120209114103] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report serial CT and MRI findings in a biopsy-proven case of cerebral amyloid angiopathy (CAA) with isolated angiitis of the central nervous system (CNS). A 69-year-old man had developed dizziness, dementia, and generalized seizure during the preceding 4 years. An initial examination by brain CT and MRI showed bilateral symmetrical periventricular lesions closely resembling those of Binswanger's disease. Subsequently, the lesions expanded slowly, involving a large area of the right cerebral hemisphere with an obvious mass effect. Since a primary brain tumor was suspected, a brain biopsy was performed, and histopathological examination revealed amyloid beta protein CAA within the meningocortical vessels associated with perivascular monocytic cuffing, indicating the presence of isolated angiitis of the CNS. Multinucleated giant cells containing intracytoplasmic beta protein amyloid around a heavily amyloid-laden cortical vessel were also observed. This is the first case report to show sequential radiographical studies of the leukoencephalopathy associated with CAA and isolated angiitis of the CNS.
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Affiliation(s)
- Takashi Oide
- Third Department of Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan
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27
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Hoshi K, Yoshida K, Nakamura A, Tada T, Tamaoka A, Ikeda S. Cessation of cerebral hemorrhage recurrence associated with corticosteroid treatment in a patient with cerebral amyloid angiopathy. Amyloid 2000; 7:284-8. [PMID: 11132098 DOI: 10.3109/13506120009146443] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report the case of a 65 year old female patient with biopsy-proven cerebral amyloid angiopathy (CAA). She experienced intracerebral hemorrhages 4 times during 23 days but these serious strokes did not recur after corticosteroid therapy was started and her condition greatly improved. Since high titers of antinuclear antibodies and elevated erythrocyte sedimentation rate were found in her serum, she may have an inflammatory disorder involving amyloid-laden cerebral vessels. This is the first report showing the usefulness ofcorticosteroid for the treatment of CAA-related cerebral hemorrhages. Additionally, the concentrations of Abeta40 and Abeta42 in the CSF of this patient decreased rapidly after the use of corticosteroid, and ultimately fell far below normal values.
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Affiliation(s)
- K Hoshi
- Department of Medicine (Neurology), Shinshu University School of Medicine, Matsumoto, Japan
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28
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Abstract
Central nervous system (CNS) vasculitis occurs in a variety of clinical settings. Some exhibit a distinct age preference; others a tissue tropism. Most frequently encountered are giant cell arteritis (temporal arteritis) and vasculitis secondary to infections. The CNS may be involved in the systemic vasculitides, and neurologic abnormalities occasionally appear as a presenting manifestation of disease. Isolated angiitis of the CNS, a rare form of vasculitis restricted to the CNS, must be distinguished from other causes of CNS inflammation and from noninflammatory vascular disease. We are learning a great deal about the cellular mechanisms of vascular inflammation in the brain. Some manifestations of the clinical disease result from histologic features of the infiltrate and the size of affected vessel. However, the local consequences of inflammation such as increased coagulation and altered vasomotor tone, as well as the systemic consequences such as activation of the central noradrenergic systems, trigeminovascular system, and hypothalamic pituitary adrenal axis contribute to both pathogenesis of disease and recovery. Two central issues that confront us now are improving the accuracy of the diagnosis (including identifying any underlying infectious causes) and limiting the long-term damage both from disease and its therapies.
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Affiliation(s)
- P M Moore
- Department of Neurology, University of Pittsburgh, 3471 Fifth Avenue, Suite 811, Pittsburgh, PA 15213, USA
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29
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Abstract
The vasculitides are a collection of diseases sharing the central feature of tissue injury due to inflammation of blood vessels. Although some occur frequently, many are encountered uncommonly or rarely. Nonetheless, because peripheral or central nervous system abnormalities may be a prominent part of these disorders, neurologists should know or be able to refer to studies on the classification, pathophysiology, treatments, and long-term complications of vasculitis. Two central issues that confront us now are 1) improving the accuracy of diagnosis, including identifying any underlying infectious causes, and 2) limiting the long-term damage from both the disease and its therapies.
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30
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Abstract
Cerebral amyloid angiopathy (CAA) is characterized by amyloid deposition in cortical and leptomeningeal vessels. Several cerebrovascular amyloid proteins (amyloid beta-protein (Abeta), cystatin C (ACys), prion protein (AScr), transthyretin (ATTR), gelsolin (AGel), and ABri (or A-WD)) have been identified, leading to the classification of several types of CAA. Sporadic CAA of Abeta type is commonly found in elderly individuals and patients with Alzheimer's disease. Cerebral amyloid angiopathy is an important cause of cerebrovascular disorders including lobar cerebral hemorrhage, leukoencephalopathy, and small cortical hemorrhage and infarction. We review the clinicopathological and molecular aspects of CAA and discuss the pathogenesis of CAA with future perspectives.
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Affiliation(s)
- M Yamada
- Department of Neurology, Kanazawa University School of Medicine, Japan.
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31
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Abstract
Vascular inflammation stands at the center of innumerable physiological and pathological processes. Dissecting the mechanisms of successful vascular injury and repair, investigators provide information for scientists and clinicians. The neurologist benefits from studies across several disciplines. Details of the cellular functions in the infiltrates of temporal arteries impart a basis for rational therapy. The interactions of herpes virus with vessels wall remind us of the affinity of numerous infectious agents for the vasculature. Several animal models are enabling us to explore the genetic links in autoimmunity. Although clinical studies may not yet provide us with answers for accurate diagnosis and treatment of many of our patients, data from this year will keep our interest high.
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Affiliation(s)
- P M Moore
- Department of Neurology, University of Pittsburgh, Pennsylvania 15213, USA
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