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Bilodeau PA, Dickson JR, Kozberg MG. The Impact of Anti-Amyloid Immunotherapies on Stroke Care. J Clin Med 2024; 13:1245. [PMID: 38592119 PMCID: PMC10931618 DOI: 10.3390/jcm13051245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Anti-amyloid immunotherapies have recently emerged as treatments for Alzheimer's disease. While these therapies have demonstrated efficacy in clearing amyloid-β and slowing cognitive decline, they have also been associated with amyloid-related imaging abnormalities (ARIA) which include both edema (ARIA-E) and hemorrhage (ARIA-H). Given that ARIA have been associated with significant morbidity in cases of antithrombotic or thrombolytic therapy, an understanding of mechanisms of and risk factors for ARIA is of critical importance for stroke care. We discuss the latest data regarding mechanisms of ARIA, including the role of underlying cerebral amyloid angiopathy, and implications for ischemic stroke prevention and management.
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Affiliation(s)
- Philippe A. Bilodeau
- Division of Neuroimmunology and Neuroinfectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - John R. Dickson
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, 114 16th Street, Charlestown, Boston, MA 02129, USA;
| | - Mariel G. Kozberg
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, 114 16th Street, Charlestown, Boston, MA 02129, USA;
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Seifert RM, Rauch M, Klingebiel R, Boese LM, Greeve I, Rudwaleit M, Schäbitz WR. Case report: Cerebral amyloid angiopathy-related inflammation in a patient with granulomatosis with polyangiitis. Front Neurol 2023; 14:1277843. [PMID: 38020617 PMCID: PMC10666051 DOI: 10.3389/fneur.2023.1277843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Cerebral amyloid angiopathy-related inflammation (CAA-ri) defines a subacute autoimmune encephalopathy, which is presumably caused by increased CSF concentrations of anti-Aβ autoantibodies. This autoinflammatory reaction is temporally and regionally associated with microglial activation, inflammation and radiological presence of vasogenic edema. Clinical characteristics include progressive demential development as well as headache and epileptic seizures. In the absence of histopathologic confirmation, the criteria defined by Auriel et al. allow diagnosis of probable resp. possible CAA-ri. CAA-ri shows responsiveness to immunosuppressive therapies and a possible coexistence with other autoinflammatory diseases. Methods We present a case report and literature review on the diagnosis of CAA-ri in a patient with known granulomatosis with polyangiitis (GPA). Results Initially, the presented patient showed neuropsychiatric abnormalities and latent arm paresis. Due to slight increase in CSF cell count, an initial antiviral therapy was started. MR tomography showed a pronounced frontotemporal edema as well as cerebral microhemorrhages, leading to the diagnosis of CAA-ri. Subsequent high-dose steroid treatment followed by six intravenous cyclophosphamide pulses resulted in decreased CSF cell count and regression of cerebral MRI findings. Conclusion The symptoms observed in the patient are consistent with previous case reports on CAA-ri. Due to previously known GPA, we considered a cerebral manifestation of this disease as a differential diagnosis. However, absence of pachymeningitis as well as granulomatous infiltrations on imaging made cerebral GPA less likely. An increased risk for Aβ-associated pathologies in systemic rheumatic diseases is discussed variously.
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Affiliation(s)
- Rebecca M. Seifert
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Michael Rauch
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Lennart-Maximilian Boese
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Isabell Greeve
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Martin Rudwaleit
- Universitätsklinik für Innere Medizin und Rheumatologie, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
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Storti B, Gabriel MM, Sennfält S, Canavero I, Rifino N, Gatti L, Bersano A. Rare forms of cerebral amyloid angiopathy: pathogenesis, biological and clinical features of CAA-ri and iCAA. Front Neurosci 2023; 17:1219025. [PMID: 37492402 PMCID: PMC10363735 DOI: 10.3389/fnins.2023.1219025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/22/2023] [Indexed: 07/27/2023] Open
Abstract
Thanks to a more widespread knowledge of the disease, and improved diagnostic techniques, the clinical spectrum of cerebral amyloid angiopathy (CAA) is now broad. Sporadic CAA, hereditary CAA, CAA-related inflammation (CAA-ri) and iatrogenic CAA (iCAA) create a clinical and radiological continuum which is intriguing and only partially discovered. Despite being relatively rare, CAA-ri, an aggressive subtype of CAA with vascular inflammation, has gained growing attention also because of the therapeutic efficacy of anti-inflammatory and immunomodulating drugs. More recently, diagnostic criteria have been proposed for an unusual variant of CAA, probably related to an iatrogenic origin (iCAA), toward which there is mounting scientific interest. These atypical forms of CAA are still poorly known, and their recognition can be challenging and deserve to be pursued in specialized referral centres. The aim of this brief review is to focus current developments in the field of rare forms of CAA, its pathogenesis as well as clinical and biological features in order to increase awareness of these rare forms.
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Affiliation(s)
- Benedetta Storti
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Maria Magdalena Gabriel
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Stefan Sennfält
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Isabella Canavero
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nicola Rifino
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Gatti
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Anna Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Li D, Qin W, Guo Y, Xia M, Li S, Zhang J, Zang W. Clinical, laboratory, and radiological features of cerebral amyloid angiopathy-related inflammation (CAA-ri): retrospective, observational experience of a single centre. Neurol Sci 2023; 44:631-638. [PMID: 36207650 DOI: 10.1007/s10072-022-06436-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a subtype of CAA with an inflammatory response to the vascular β-amyloid deposits. Reliable and non-invasive clinical diagnostic methods may allow patients to avoid the side effects of brain biopsy. OBJECTIVE In this observational study, we retrospectively analyzed the clinical, laboratory, radiological features, treatment, and outcome of patients diagnosed with CAA-ri. The main purpose is to enhance knowledge of CAA-ri and to avoid misdiagnosis. METHODS We described 15 consecutive patients with probable or possible CAA-ri at Henan Provincial People's Hospital according to a validation study of proposed criteria for the diagnosis of CAA-ri. The clinical features, imaging, laboratory findings, and treatment which included the response to immunotherapy were revealed in the study. RESULTS The median age of 15 patients was 67.0 years (range 48.0-90.0 years), and the male-to-female ratio was 7: 8. In our study, the most common clinical manifestations were cognitive decline (7/15, 46.7%), focal neurologic deficit (6/15, 40.0%), and headache (5/15, 33.3%). In terms of imaging results, white matter hyperintensity (WMH) lesions were rarely seen in the cerebellum and brainstem, while no hemorrhagic lesion was observed in the brainstem of all 15 patients. In addition, 12 patients (80.0%) showed improvement or stability for the clinical and radiological outcomes after immunotherapy. CONCLUSION CAA-ri should be considered as a differential diagnosis when brain MRI shows typical features in the elderly. Once the diagnosis is established, immunotherapy should be initiated as early as possible to promote neurological function recovery and reduce recurrence.
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Affiliation(s)
- Dan Li
- Department of Neurology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Weiwei Qin
- Department of Neurology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Yang Guo
- Department of Neurosurgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, 450003, Zhengzhou, China
| | - Mingrong Xia
- Department of Neurology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Siyuan Li
- Department of Neurology, Dengfeng People's Hospital, Dengfeng, 452470, Henan, China
| | - Jiewen Zhang
- Department of Neurology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Weizhou Zang
- Department of Neurology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China.
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8
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Tabaee Damavandi P, Storti B, Fabin N, Bianchi E, Ferrarese C, DiFrancesco JC. Epilepsy in cerebral amyloid angiopathy: an observational retrospective study of a large population. Epilepsia 2023; 64:500-510. [PMID: 36515439 DOI: 10.1111/epi.17489] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a major cause of spontaneous intracranial hemorrhage in older adults. Epilepsy represents a possible sequela of the disease. To date, studies on epilepsy in CAA are lacking, and the few data available mainly focus on CAA-related inflammation (CAA-ri), the inflammatory form of the disease. METHODS In this retrospective observational study, we consecutively recruited CAA patients observed over a time span of 10 years, collecting demographic, clinical, and instrumental data. Significant baseline characteristics were evaluated as potential risk factors for the development of epilepsy in the CAA population, and in the subgroups of CAA-ri and CAA without inflammatory reaction (CAA-nri). The effect of potential risk factors for epilepsy was measured as odds ratio with 95% confidence interval. RESULTS Within 96 recruited CAA cases, 33 (34.4%) developed epilepsy during follow-up (median = 13.5 months). The prevalent type of seizure was focal (81.3%); 12.1% of the epileptic patients presented status epilepticus, and 6.1% developed drug-resistant epilepsy. Electroencephalographic traces revealed slow and epileptic discharge activity in the majority of epileptic patients, but also in those without epilepsy. The presence of focal or disseminated cortical superficial siderosis (cSS) was associated with an increased risk of epilepsy in the CAA-nri group, and the association with CAA-ri and epilepsy was present in the overall population. SIGNIFICANCE Epilepsy is a common manifestation during the course of CAA, where CAA-ri and cSS represent predisposing factors for the development of seizures. These data suggest the importance of a deep characterization of CAA patients, to better select those more prone to develop epilepsy.
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Affiliation(s)
- Payam Tabaee Damavandi
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Benedetta Storti
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Natalia Fabin
- Laboratory of Epidemiological and Clinical Cardiology, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Elisa Bianchi
- Neurological Disorders, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Carlo Ferrarese
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
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Salvarani C, Paludo J, Hunder GG, Ansell SM, Giannini C, Parisi JE, Huston J, Koster MJ, Warrington KJ, Croci S, Brown RD. Exploring Gene Expression Profiles in Primary Central Nervous System Vasculitis. Ann Neurol 2023; 93:120-130. [PMID: 36264136 DOI: 10.1002/ana.26537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study was undertaken to explore the gene expression profile of primary central nervous system vasculitis (PCNSV). METHODS Brain specimens of 4 patients with granulomatous vasculitis (GV), 5 with lymphocytic vasculitis (LV), 4 with amyloid β-related angiitis (ABRA), and 4 normal controls were studied. RNA-sequencing was performed using the Illumina Hiseq-4,000 platform and the Illumina TruSeq Total-RNA library. Student t test and false discovery rate tests were performed for each of the differentially expressed transcripts. Ingenuity Pathway Analysis was used for the pathway expression analysis. CIBERSORT was used to estimate the abundances of different immune cell subsets in the tissues based on gene expression data. RESULTS Transcripts differentially expressed between PCNSV and normal brain indicated that endosomal, mitochondrial, and ribosome dysfunction, alterations in protein synthesis, and noncoding RNAs might be involved in PCNSV. Pathway analysis revealed the activation of dendritic cell maturation and antigen processing as well as neuroinflammation in PCNSV versus normal brain, whereas oxidative phosphorylation was inhibited. CIBERSORT estimation of immune cell subsets suggested that activated NK cells, M1 macrophages, memory B cells, and follicular helper T cells were likely to be more prevalent in PCNSV samples. Naïve CD4 T cells and monocytes were mainly estimated to be present in GV and ABRA. Plasma cell and γδ T-cell signatures were mainly found in LV and normal brain. GV showed higher levels of genes associated with macrophage activities and T cells. ABRA showed higher levels of long noncoding RNAs and miR-616. LV showed higher levels of genes encoding immunoglobulins. INTERPRETATION RNA sequencing confirmed PCNSV heterogeneity. ANN NEUROL 2023;93:120-130.
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Affiliation(s)
- Carlo Salvarani
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Division of Rheumatology, Local Health Unit Company-Institute of Hospitalization and Scientific Care, Reggio Emilia, Italy
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Gene G Hunder
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Joseph E Parisi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Stefania Croci
- Clinical Immunology, Allergy and Advanced Biotechnologies Unit, USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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10
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Yang JY, Chu YT, Tsai HH, Jeng JS. Amyloid and tau PET in cerebral amyloid angiopathy-related inflammation two case reports and literature review. Front Neurol 2023; 14:1153305. [PMID: 37188315 PMCID: PMC10175602 DOI: 10.3389/fneur.2023.1153305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
Background Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a clinical syndrome characterized by MRI findings of amyloid-related imaging abnormalities-edema (ARIA-E) suggestive of autoimmune and inflammatory reaction and hemorrhagic evidence of cerebral amyloid angiopathy. The longitudinal variation of amyloid PET and its imaging association with CAA-ri are undetermined. Moreover, tau PET in CAA-ri has been rarely investigated. Method We retrospectively described two cases of CAA-ri. We provided the temporal change of amyloid and tau PET in the first case, and the cross-sectional finding of amyloid and tau PET in the second case. We also performed a literature review of the imaging features of amyloid PET in reported cases of CAA-ri. Results In the first case, an 88-year-old male presented with progressive consciousness and gait disturbances over 2 months. MRI showed disseminated cortical superficial siderosis. Amyloid PET prior to and after the CAA-ri revealed focally decreased amyloid load in the region of ARIA-E. In the second case, a 72-year-old male was initially suspected to have central nervous system cryptococcosis but later diagnosed with CAA-ri because of the characteristic MRI features and good response to corticosteroid treatment; a subsequent amyloid scan revealed positive amyloid deposition of the brain. Neither case suggested an association between the region of ARIA-E and higher amyloid uptake on PET before or after onset of CAA-ri. Our literature review revealed variable findings related to amyloid burden in post-inflammatory regions in previously reported CAA-ri cases with available amyloid PET. Our case is the first report of longitudinal changes on amyloid PET and show focal decreases in amyloid load after the inflammatory process. Conclusion This case series highlights the need to better explore the potential of longitudinal amyloid PET in the understanding of the mechanisms of CAA-ri.
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Affiliation(s)
- Jhih-Yong Yang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Tsai Chu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
- *Correspondence: Hsin-Hsi Tsai
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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11
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Reisz Z, Troakes C, Sztriha LK, Bodi I. Fatal thrombolysis-related intracerebral haemorrhage associated with amyloid-β-related angiitis in a middle-aged patient - case report and literature review. BMC Neurol 2022; 22:500. [PMID: 36564732 PMCID: PMC9783436 DOI: 10.1186/s12883-022-03029-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Amyloid-β-related angiitis (ABRA) is a rare complication of cerebral amyloid angiopathy, characterized by amyloid-β deposition in the leptomeningeal and cortical vessels with associated angiodestructive granulomatous inflammation. The clinical presentation is variable, including subacute cognitive decline, behavioural changes, headaches, seizures and focal neurological deficits, which may mimic other conditions. Here, we present a case with fatal thrombolysis-related haemorrhage associated with ABRA in a middle-aged patient. CASE PRESENTATION A 55-year-old man was admitted to hospital with sudden onset left-sided cheek, arm and hand sensory loss, blurred vision, and worsening headache, with a National Institutes of Health Stroke Scale (NIHSS) score of 3. An acute CT head scan showed no contraindications, and therefore the decision was made to give intravenous thrombolysis. Post-thrombolysis, he showed rapid deterioration with visual disturbances, headache and confusion, and a repeat CT head scan confirmed several areas of intracerebral haemorrhage. No benefit from surgical intervention was expected, and the patient died four days after the first presentation. Neuropathological examination found acute ischemic infarcts of three to five days duration in the basal ganglia, insular cortex and occipital lobe, correlating with the initial clinical symptoms. There were also extensive recent intracerebral haemorrhages most likely secondary to thrombolysis. Furthermore, the histological examination revealed severe cerebral amyloid angiopathy associated with granulomatous inflammatory reaction, consistent with ABRA. CONCLUSIONS Presentation of ABRA in a middle-aged patient highlighted the difficulties in recognition and management of this rare condition. There is emerging evidence that patients with CAA may have increased risk of fatal intracerebral haemorrhages following thrombolysis. This may be further increased by a coexisting CAA-related inflammatory vasculopathy which is potentially treatable with steroid therapy if early diagnosis is made.
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Affiliation(s)
- Zita Reisz
- grid.429705.d0000 0004 0489 4320Department of Clinical Neuropathology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Claire Troakes
- grid.13097.3c0000 0001 2322 6764London Neurodegenerative Diseases Brain Bank, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Laszlo K. Sztriha
- grid.429705.d0000 0004 0489 4320Department of Neurology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Istvan Bodi
- grid.429705.d0000 0004 0489 4320Department of Clinical Neuropathology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK ,grid.13097.3c0000 0001 2322 6764London Neurodegenerative Diseases Brain Bank, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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12
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Theodorou A, Palaiodimou L, Safouris A, Kargiotis O, Psychogios K, Kotsali-Peteinelli V, Foska A, Zouvelou V, Tzavellas E, Tzanetakos D, Zompola C, Tzartos JS, Voumvourakis K, Paraskevas GP, Tsivgoulis G. Cerebral Amyloid Angiopathy-Related Inflammation: A Single-Center Experience and a Literature Review. J Clin Med 2022; 11. [PMID: 36431207 DOI: 10.3390/jcm11226731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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13
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Singh B, Lavezo J, Gavito-Higueroa J, Ahmed F, Narasimhan S, Brar S, Cruz-Flores S, Kraus J. Updated Outlook of Cerebral Amyloid Angiopathy and Inflammatory Subtypes: Pathophysiology, Clinical Manifestations, Diagnosis and Management. J Alzheimers Dis Rep 2022; 6:627-639. [DOI: 10.3233/adr-220055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/17/2022] [Indexed: 11/15/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a common untreatable cause of lobar hemorrhages and cognitive decline in the older population. Subset of patients present with its inflammatory subtype with rapid decline in cognitive functions and neurological deficits. Most commonly the underlying pathophysiology of this disease is deposition of insoluble amyloid protein into blood vessel walls which results in vessel fragility leading to local neurotoxicity which may eventually leads to lobar hemorrhages and cognitive decline. The term “Amyloid Spell” encompasses transient focal neurological deficits which is commonly misdiagnosed as seizures or transient ischemic attack in the emergency department. Radiologic findings in these patients may reveal microbleeds, cortical superficial siderosis, white matter hyperintensities, and cerebral edema which support the clinical diagnosis which could be otherwise challenging. CAA diagnostic criteria require CT (Edinburgh Criteria) or MRI imaging, or neuropathology. The diagnosis can be suspected without imaging or neuropathology but cannot be confirmed. This review article provides a critical outlook on different types of presentations, updated diagnostic criteria and management of CAA patients illustrating underlying mechanisms associated with neuronal injury secondary to amyloid deposition.
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Affiliation(s)
- Baljinder Singh
- Department of Neurology, Texas Tech University Health Sciences Center, TX, USA
| | - Jonathan Lavezo
- Department of Neurology, Texas Tech University Health Sciences Center, TX, USA
| | | | - Faiza Ahmed
- Department of Neurology, Texas Tech University Health Sciences Center, TX, USA
| | | | - Simrandeep Brar
- Department of Neurology, Texas Tech University Health Sciences Center, TX, USA
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14
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Romano N, Urru A, Castaldi A. Imaging of cerebral amyloid angiopathy–related inflammation (CAA-ri). Neurol Sci 2022; 43:6151-6153. [DOI: 10.1007/s10072-022-06189-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
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15
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Cancelloni V, Rufa A, Battisti C, De Stefano N, Mastrocinque E, Garosi G, Venezia D, Chiarotti I, Cerase A. Diagnosis, treatment, and follow-up of patients with cerebral amyloid angiopathy-related inflammation. Neurol Sci 2022. [PMID: 35930182 PMCID: PMC9616779 DOI: 10.1007/s10072-022-06299-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022]
Abstract
Purpose Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare potentially reversible encephalopathy associated with an autoimmune process against proteins deposited in the walls of cortical and leptomeningeal brain vessels. Definite diagnosis requires histopathological features of vascular inflammation and amyloid deposition from brain biopsy. Clinical-neuroradiological criteria have been recently introduced and validated to reduce the need for biopsy. The purpose of this paper is to report a historical retrospective review of clinical-neuroradiological follow-up of two patients with probable CAA-ri and five patients with a reasonably probable suspect of CAA-ri (4 females, 3 males, patient’s age at admission: 66–79 years) seen at our institution between 2007 and 2021, focusing on clinical and neuroradiological awareness to this entity and variable response to immunotherapy. Materials and methods Clinical features at presentation included subacute to acute confusion (6/7), seizures (4/7), cognitive impairment (5/7), and focal neurological signs (3/7). Neuroradiology included braincomputed tomography followed by magnetic resonance imaging. Infectious diseases and autoimmune workups were then performed. Results CSF analysis was performed in two patients. Cerebral angiography was performed in two patients, to rule out vascular malformations. Hemorrhagic posterior reversible encephalopathy syndrome has been suspected in two patients. Four patients underwent immunotherapy with corticosteroids followed by reduction of brain dysfunctions. Three patients did not undergo immunotherapy but underwent clinical and/or neuroradiological remission. Conclusions Patients with CAA-ri present a rare steroid-responsive acute to subacute brain dysfunction. Thus, it has to be known and recognized both clinically and neuroradiologically. Spontaneous clinical and/or neuroradiological improvement is possible in patients with mild symptoms.
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16
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Tanner JA, Richie MB, Cadwell CR, Eliaz A, Kim S, Haq Z, Rasool N, Shah MP, Guterman EL. Amyloid-β related angiitis presenting as eosinophilic meningitis: a case report. BMC Neurol 2022; 22:116. [PMID: 35331158 PMCID: PMC8944059 DOI: 10.1186/s12883-022-02638-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/14/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Eosinophilic meningitis is uncommon and often attributed to infectious causes. CASE PRESENTATION We describe a case of a 72-year-old man who presented with subacute onset eosinophilic meningitis, vasculitis, and intracranial hypertension with progressive and severe neurologic symptoms. Brain MRI demonstrated multifocal strokes and co-localized right temporo-parieto-occipital vasogenic edema, cortical superficial siderosis, and diffuse leptomeningeal enhancement. He ultimately underwent brain biopsy with immunohistochemical stains for amyloid-β and Congo red that were extensively positive in the blood vessel walls and in numerous diffuse and neuritic parenchymal confirming a diagnosis of amyloid-β related angiitis. He was treated with immunosuppression with clinical stabilization. CONCLUSIONS Amyloid-β related angiitis is an underrecognized cause of eosinophilic meningitis that can present fulminantly and is typically responsive to immunosuppression. The presence of eosinophils may provide additional clues to the underlying pathophysiology of amyloid-β related angiitis.
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Affiliation(s)
- Jeremy A Tanner
- Department of Neurology, University of California, San Francisco (UCSF), 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA, 94143, USA
| | - Megan B Richie
- Department of Neurology, University of California, San Francisco (UCSF), 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA, 94143, USA
| | - Cathryn R Cadwell
- Department of Anatomic Pathology, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Amity Eliaz
- School of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Shannen Kim
- School of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Zeeshan Haq
- Department of Ophthalmology, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Nailyn Rasool
- Department of Neurology, University of California, San Francisco (UCSF), 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA, 94143, USA
- Department of Ophthalmology, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Maulik P Shah
- Department of Neurology, University of California, San Francisco (UCSF), 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA, 94143, USA
| | - Elan L Guterman
- Department of Neurology, University of California, San Francisco (UCSF), 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA, 94143, USA.
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17
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Abstract
A 73-year-old woman developed cognitive decline over 1 year. MR scan of the brain showed a focal asymmetrical leukoencephalopathy involving the right frontal, temporal, parietal and occipital lobes. Extensive laboratory investigations found no cause but brain biopsy identified amyloid-beta-related angiitis (ABRA), a potentially treatable cause of rapid-onset dementia. We gave intravenous methylprednisolone and then two courses of intravenous cyclophosphamide, after which her cognitive skills gradually but significantly improved over several months.
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Affiliation(s)
- Memoona Nasir
- Department of Neurology, Queen's Hospital, Romford, UK
| | - Donald Nortey
- Department of Neurology, Queen's Hospital, Romford, UK
| | - Naveed Malek
- Department of Neurology, Queen's Hospital, Romford, UK
| | - Fernanda Valerio
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
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18
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Paul SA, Roy D, Mondal GP, Bhattacharyya R, Ghosh KC, Das S, Krishna H, Patra C, Kiran J, Benito-león J. Primary angiitis of central nervous system – A challenging diagnosis. J Neuroimmunol 2022. [DOI: 10.1016/j.jneuroim.2022.577844] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/26/2022] [Accepted: 03/06/2022] [Indexed: 12/14/2022]
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19
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Grasso D, Castorani G, Borreggine C, Simeone A, De Blasi R. Cerebral amyloid angiopathy related inflammation: A little known but not to be underestimated disease. Radiol Case Rep 2021; 16:2514-2521. [PMID: 34257791 PMCID: PMC8260958 DOI: 10.1016/j.radcr.2021.05.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Cerebral amyloid angiopathy related inflammation (CAA-ri) is a rare encephalopathy resulting from perivascular inflammation after β-βamyloid (A) deposition in cerebral vessels leading to progressive dementia, focal neurological signs, seizures and intracerebral hemorrhages. This condition is characterized on magnetic resonance imaging (MRI) by patchy or confluent T2/fluid attenuation inversion recovery (FLAIR) hyperintensities in the cortex and subcortical white matter located mainly in the same areas of pre-existing multiple microhemorrhages. In this report of 2 cases of “probable” CAA-ri women aged 71 and 68, we propose a review on the pathophysiological, clinical, radiological, therapeutic and prognostic aspects of this little-known and poor outcome condition. Even though an apparently favorable initial evolution after steroid and/or immunosuppressive treatment, CAA-ri course is unpredictable and often associated with low survival rates. We suggest the importance of timely and proper clinico-radiological evaluation in suspected CAA-ri cases, in order to start an appropriate treatment even without the brain biopsy.
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Affiliation(s)
- Daniela Grasso
- IRCCS Ospedale Casa Sollievo della Sofferenza, Department of Diagnostic Imaging, San Giovanni Rotondo, Italy
- Corresponding author.
| | - Giulia Castorani
- University of Foggia Postgraduate Medical School, Diagnostic Imaging, Foggia, Italy
| | - Carmela Borreggine
- IRCCS Ospedale Casa Sollievo della Sofferenza, Department of Diagnostic Imaging, San Giovanni Rotondo, Italy
| | - Annalisa Simeone
- IRCCS Ospedale Casa Sollievo della Sofferenza, Department of Diagnostic Imaging, San Giovanni Rotondo, Italy
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20
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Roca CU, Gonzalez FM, Bala MI, Saucedo M, Bandeo L, Cejas LL, Pacha S, Bonardo P, Rugilo C, Dezanzo P, Torino R, Sevlever G, Pardal MF, Reisin R. Pseudotumoral Presentation of Cerebral Amyloid-Beta Angiopathy: Case Report and Review of Literature. Psychiatry Investig 2021; 18:479-485. [PMID: 34130443 PMCID: PMC8256143 DOI: 10.30773/pi.2020.0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/01/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare and potentially treatable encephalopathy that usually affects people older than 50 years old and has an acute or subacute clinical presentation characterized by rapidly evolving cognitive decline, focal deficits and seizures. In a small subset of patients the disease can adopt a pseudotumoral form in the neuroimages that represents a very difficult diagnostic challenge. METHODS Here in we report a patient with a tumour-like presentation of histopathologically confirmed CAA-RI. RESULTS We also conducted a search and reviewed the clinical and radiological features of 41 cases of pseudotumoral CAA-RI previously reported in the literature in order to identify those characteristics that should raise diagnostic suspicions of the disease, there by avoiding unnecessary surgical treatments. CONCLUSION The therapy of CAA-RI with steroids is usually effective and clinical and radiological remission can be achieved in the first month in approximately 70% of cases.
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Affiliation(s)
- Claudia Uribe Roca
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | | | - Marta Ines Bala
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Miguel Saucedo
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Lucrecia Bandeo
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Luciana Leon Cejas
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Sol Pacha
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Pablo Bonardo
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Carlos Rugilo
- Department of Neuroradiology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Pablo Dezanzo
- Department of Pathology, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Rafael Torino
- Department of Neurosurgery, Buenos Aires British Hospital, Buenos Aires, Argentina
| | | | | | - Ricardo Reisin
- Department of Neurology, Buenos Aires British Hospital, Buenos Aires, Argentina
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21
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Sakai K, Noguchi‐Shinohara M, Ikeda T, Hamaguchi T, Ono K, Yamada M. Cerebrospinal fluid cytokines and metalloproteinases in cerebral amyloid angiopathy-related inflammation. Acta Neurol Scand 2021; 143:450-457. [PMID: 33247941 DOI: 10.1111/ane.13382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/06/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To clarify pathomechanisms of cerebral amyloid angiopathy-related inflammation/vasculitis (CAA-ri). METHODS We collected cerebrospinal fluid (CSF) samples of nine patients with CAA-ri of before (acute CAA-ri group) and after treatment (post-treatment CAA-ri group) and nine patients with CAA (CAA without inflammation group). We examined anti-amyloid β protein (Aβ) antibody titer by ELISA, and measured 27 Cytokines, nine matrix metalloproteinases (MMPs), and four tissue inhibitors of MMPs (TIMPs) by multiplexed fluorescent bead-based immunoassay. RESULTS We demonstrated TIMP-2 (median) in CSF of the acute CAA-ri group (30,994.49 pg/ml, p = 0.007) and the post-treatment CAA-ri group (36,430.97 pg/ml, p = 0.001) was significantly elevated compared to that of the CAA without inflammation group (22,013.58 pg/ml). TIMP-1 was also higher in the post-treatment CAA-ri group than that in the CAA without inflammation group (58,167.75 pg/ml vs. 45,770.03 pg/ml, p = 0.005). There was a significant positive correlation between TIMP-1 and anti-Aβ antibodies in CAA-ri (rs = 0.900, p = 0.037). Median MMP-2 tended to be higher in the acute and post-treatment CAA-ri groups (10,619.82 pg/ml and 8396.98 pg/ml, respectively) than in the CAA without inflammation group (4436.34 pg/ml). Platelet-derived growth factor (PDGF)-BB levels before treatment were higher than those after treatment (median, 12.66 pg/ml vs. 6.39 pg/ml; p = 0.011) and correlated with the titer of anti-Aβ antibodies (rs =0.900, p = 0.037). CONCLUSIONS Elevated levels of MMP-2, TIMP-1, and TIMP-2 might be related to the development of CAA-ri. Elevation of PDGF-BB could be a useful marker for clinical diagnosis of CAA-ri.
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Affiliation(s)
- Kenji Sakai
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Moeko Noguchi‐Shinohara
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Preemptive Medicine for Dementia Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Tokuhei Ikeda
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Neurology Ishikawa Prefectural Central Hospital Kanazawa Japan
| | - Tsuyoshi Hamaguchi
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Kenjiro Ono
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
- Department of Neurology Showa University School of Medicine Tokyo Japan
| | - Masahito Yamada
- Department of Neurology and Neurobiology of Aging Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
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22
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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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23
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Abstract
ABSTRACT Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare but increasingly recognized subtype of CAA. CAA-RI consists of two subtypes: inflammatory cerebral amyloid angiopathy and amyloid β (Aβ)-related angiitis. Acute or subacute onset of cognitive decline or behavioral changes is the most common symptom of CAA-RI. Rapid progressive dementia, headache, seizures, or focal neurological deficits, with patchy or confluent hyperintensity on T2 or fluid-attenuated inversion recovery sequences and evidence of strictly lobar microbleeds or cortical superficial siderosis on susceptibility-weighted imaging imply CAA-RI. The gold standard for diagnosis is autopsy or brain biopsy. However, biopsy is invasive; consequently, most clinically diagnosed cases have been based on clinical and radiological data. Other diagnostic indexes include the apolipoprotein E ε4 allele, Aβ and anti-Aβ antibodies in cerebral spinal fluid and amyloid positron emission tomography. Many diseases with similar clinical manifestations should be carefully ruled out. Immunosuppressive therapy is effective both during initial presentation and in relapses. The use of glucocorticoids and immunosuppressants improves prognosis. This article reviews the pathology and pathogenesis, clinical and imaging manifestations, diagnostic criteria, treatment, and prognosis of CAA-RI, and highlights unsolved problems in the existing research.
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Rempe T, Sollero CEV, Rodriguez E, Viswanathan VT, Carlson A, Rees J, Tuna IS, Kresak J, Gyang TV. Corticosteroids lead to short-term improvement in cerebral amyloid angiopathy-related inflammation. J Neuroimmunol 2020; 348:577377. [PMID: 32919147 DOI: 10.1016/j.jneuroim.2020.577377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/08/2020] [Accepted: 08/24/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy - related inflammation (CAA-ri) is an uncommon manifestation of CAA. METHODS Single-center, retrospective review of all charts with ICD-code I68.0 (CAA) from 2/2/2016-1/1/2020. RESULTS Of 152 CAA cases, 13 (8.6%) were consistent with CAA-ri. Corticosteroid-treatment led to short-term reduction in modified Rankin Scale scores (2.6 ± 1.4 vs. 1.6 ± 1.5; p = 0.01) and T2/FLAIR lesion volume (78.1 ± 52.2 cm3 vs. 30 ± 30.9 cm3, p < 0.01) as well as short-term improvement in post-treatment Clinical Global Impression - Global Change scores compared to pre-treatment scores (clinical: 6 ± 1 vs. 2.6 ± 1.3, p = 0.03; radiological: 4.6 ± 1.9 vs. 1.2 ± 0.4, p = 0.03). INTERPRETATION Corticosteroid-treatment leads to clinical and radiological short-term improvement (class IV evidence).
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25
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Nelson T, Leung B, Bannykh S, Shah KS, Patel J, Dumitrascu OM. Cerebral Amyloid Angiopathy-Related Inflammation in the Immunosuppressed: A Case Report. Front Neurol 2019; 10:1283. [PMID: 31866934 PMCID: PMC6908508 DOI: 10.3389/fneur.2019.01283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/19/2019] [Indexed: 11/13/2022] Open
Abstract
Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an immune-mediated disorder of the central nervous system characterized by an inflammatory response to amyloid-beta (Aβ) deposition within cerebral blood vessel walls. Immunosuppressive therapy is the mainstay of treatment. We present a case of CAA-ri in a subject already on immunosuppressive therapy after orthotopic heart transplantation (OHT). A 57-year-old man 8 months post-OHT for sarcoid cardiomyopathy developed headaches and staring spells while hospitalized for disseminated mycobacterial infection. His brain MRI revealed bi-hemispheric T2-weighted fluid-attenuated inversion recovery white matter hyperintensities and widespread microhemorrhages. Two weeks later, he developed gait ataxia and alterations in mental status, and repeat brain MRI showed more extensive confluent white matter hyperintensities. Leptomeningeal and cortex biopsy revealed changes consistent with amyloid angiitis, with perivascular and intramural histiocyte and lymphocyte collections. Mass spectroscopy confirmed Aβ deposition. Notably, the patient was on immunosuppression with daily 5 mg oral prednisone and tacrolimus before biopsy. After high-dose intravenous followed by oral corticosteroids, he demonstrated significant clinical and radiographic improvement. No relapse was noted despite the relatively rapid tapering of the prednisone therapy over 3 months, as mandated by his systemic infection. Despite the lack of a standard treatment protocol for CAA-ri, case series have reinforced the benefit of prolonged courses of glucocorticoids as single agent or in combination with other immunomodulatory agents. Hence, management of CAA-ri in patients with disseminated mycobacterial infections or OHT is challenging. Our case is unique, as review of existing literature has not revealed any similar cases of patients on chronic immunosuppression at the time of CAA-ri diagnosis, which one would expect to protect against this disorder. In addition, CAA-ri in association with cardiopulmonary sarcoidosis was not previously reported; however, a common immunopathogenic mechanism may exist.
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Affiliation(s)
- Thomas Nelson
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Bo Leung
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Serguei Bannykh
- Division of Neuropathology, Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kevin S Shah
- Division of Heart Transplantation, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jignesh Patel
- Division of Heart Transplantation, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Oana M Dumitrascu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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26
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Poli L, De Giuli V, Piazza F, Volonghi I, Bigliardi G, Vallone S, Nichelli PF, Gasparotti R, Zini A, Padovani A, Pezzini A. A challenging diagnosis of reversible "vascular" dementia: Cerebral amyloid angiopathy-related inflammation. J Neuroimmunol 2020; 338:577109. [PMID: 31715460 DOI: 10.1016/j.jneuroim.2019.577109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare and treatable variant of CAA likely due to an autoimmune response directed toward beta-amyloid deposits. Cognitive and behavioral manifestations are the most common symptoms, followed by focal neurological signs, headache and seizures, associated with characteristics neuroradiological features on brain magnetic resonance imaging (MRI). We describe the clinical course, radiological features and therapeutic approach of two patients with probable CAA-ri with the aim of emphasizing the importance of an early diagnosis of this potentially reversible disease in different neurological settings, such as memory clinics and stroke units.
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27
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Tetsuka S, Hashimoto R. Slightly Symptomatic Cerebral Amyloid Angiopathy-Related Inflammation with Spontaneous Remission in Four Months. Case Rep Neurol Med 2019; 2019:5308208. [PMID: 31355028 DOI: 10.1155/2019/5308208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 11/18/2022] Open
Abstract
Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare variant of CAA with autoimmune inflammation. A 77-year-old female experienced light-headedness during walking and mild ataxic gait without any other objective neuropsychological deficits. Brain magnetic resonance imaging (MRI) revealed an area of abnormal signal and mild parenchymal swelling in the right parietal lobe, indicating vasogenic edema. T2⁎-weighted gradient echo imaging revealed some subcortical microbleeds in the same lesion. Based on the proposed criteria for CAA-ri, she was diagnosed with probable CAA-ri. After 4 months, the spontaneous improvement was noted in the patient's clinical and radiological findings. This report presents a rare and atypical case of CAA-ri in which the diagnosis was established after the patient underwent neuroimaging for only mild neurological symptoms, and the patient's clinical and radiological findings displayed spontaneous improvement. Despite typical and striking MRI findings of CAA-ri, this patient only presented a minimal symptom; this dissociation could highlight the significance of not misinterpreting any new neurological symptoms. Thus, increased availability of MRI and growing awareness of CAA-ri might result in more incidentally diagnosed cases in the future. Furthermore, this case suggests that it would be better to strictly monitor the clinical-radiological findings of patients with probable CAA-ri who only present with minimal symptoms without the initiation of immunosuppressive therapy.
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28
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Chantran Y, Capron J, Alamowitch S, Aucouturier P. Anti-Aβ Antibodies and Cerebral Amyloid Angiopathy Complications. Front Immunol 2019; 10:1534. [PMID: 31333665 PMCID: PMC6620823 DOI: 10.3389/fimmu.2019.01534] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/19/2019] [Indexed: 11/13/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) corresponds to the deposition of amyloid material in the cerebral vasculature, leading to structural modifications of blood vessel walls. The most frequent form of sporadic CAA involves fibrillar β-amyloid peptide (Aβ) deposits, mainly the 40 amino acid form (Aβ1-40), which are commonly found in the elderly with or without Alzheimer's disease. Sporadic CAA usually remains clinically silent. However, in some cases, acute complications either hemorrhagic or inflammatory can occur. Similar complications occurred after active or passive immunization against Aβ in experimental animal models exhibiting CAA, and in subjects with Alzheimer's disease during clinical trials. The triggering of these adverse events by active immunization and monoclonal antibody administration in CAA-bearing individuals suggests that analogous mechanisms could be involved during spontaneous CAA complications, drawing particular attention to the role of anti-Aβ antibodies. However, antibodies that react with several monomeric and aggregated forms of Aβ spontaneously occur in virtually all human individuals, hence being part of the "natural antibody" repertoire. Natural antibodies are usually described as having low-affinity and high cross-reactivity toward microbial components and autoantigens. Although frequently of the IgM class, they also belong to IgG and IgA isotypes. They likely display homeostatic functions and protective roles in aging. Until recently, the peculiar properties of these natural antibodies have hindered proper analysis of the Aβ-reactive antibody repertoire and the study of their implication in CAA complications. Herein, we review and comment the evidences of an auto-immune nature of spontaneous CAA complications, and discuss implications for forthcoming research and clinical practice.
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Affiliation(s)
- Yannick Chantran
- Sorbonne Université, Inserm, UMRS 938, Hôpital St-Antoine, AP-HP, Paris, France.,Département d'Immunologie Biologique, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Jean Capron
- Sorbonne Université, Inserm, UMRS 938, Hôpital St-Antoine, AP-HP, Paris, France.,Département de Neurologie, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Sonia Alamowitch
- Sorbonne Université, Inserm, UMRS 938, Hôpital St-Antoine, AP-HP, Paris, France.,Département de Neurologie, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Pierre Aucouturier
- Sorbonne Université, Inserm, UMRS 938, Hôpital St-Antoine, AP-HP, Paris, France.,Département d'Immunologie Biologique, Hôpital Saint-Antoine, AP-HP, Paris, France
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29
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Watanabe T, Ukon S, Kihara T, Ide YH, Matsuo S, Hayashi Y, Kasama S, Yoshikawa H, Okano Y, Uchida C, Yamamoto M, Hao H, Kimura A, Hirota S, Tsukamoto Y. An autopsy case of amyloid β-related angiitis with cognitive impairment, multiple infarcts and subcortical hemorrhage. Human Pathology: Case Reports 2018. [DOI: 10.1016/j.ehpc.2018.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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30
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Affiliation(s)
- Stewart A. Weber
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Ranish K. Patel
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Helmi L. Lutsep
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
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31
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Rajczewska-Oleszkiewicz C, Cyganek A, Stadnik A, Dziewulska D. Cerebral amyloid angiopathy-related inflammation – A case report presenting diagnostic difficulties. Neurol Neurochir Pol 2018; 52:298-305. [DOI: 10.1016/j.pjnns.2017.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/20/2017] [Accepted: 12/28/2017] [Indexed: 11/25/2022]
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32
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Taipa R, Sousa AL, Melo Pires M, Sousa N. Does the Interplay Between Aging and Neuroinflammation Modulate Alzheimer's Disease Clinical Phenotypes? A Clinico-Pathological Perspective. J Alzheimers Dis 2018; 53:403-17. [PMID: 27176075 DOI: 10.3233/jad-160121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Alzheimer's disease (AD) is a chronic neurodegenerative disorder and is the most common cause of dementia worldwide. Cumulative data suggests that neuroinflammation plays a prominent and early role in AD, and there is compelling data from different research groups of age-associated dysregulation of the neuroimmune system. From the clinical point of view, despite clinical resemblance and neuropathological findings, there are important differences between the group of patients with sporadic early-onset (<65 years old) and late-onset AD (>65 years old). Thus, it seems important to understand the age-dependent relationship between neuroinflammation and the underlying biology of AD in order to identify potential explanations for clinical heterogeneity, interpret biomarkers, and promote the best treatment to different clinical AD phenotypes. The study of the delicate balance between pro-inflammatory or anti-inflammatory sides of immune players in the different ages of onset of AD would be important to understand treatment efficacy in clinical trials and eventually, not only direct treatment to early disease stages, but also the possibility of establishing different treatment approaches depending on the age of the patient. In this review, we would like to summarize what is currently known about the interplay between "normal" age associated inflammatory changes and AD pathological mechanisms, and also the potential differences between early-onset and late-onset AD taking into account the age-related neuroimmune background at disease onset.
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Affiliation(s)
- Ricardo Taipa
- Neuropathology Unit, Department of Neuroscience, Hospital Santo António - Centro Hospitalar do Porto, Porto, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's Associate Lab, PT Government Associated Lab, Braga/Guimarães, Portugal
| | - Ana Luísa Sousa
- Department of Neurology, Hospital Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Manuel Melo Pires
- Neuropathology Unit, Department of Neuroscience, Hospital Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Nuno Sousa
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's Associate Lab, PT Government Associated Lab, Braga/Guimarães, Portugal
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33
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Schaumberg J, Trauscheid M, Eckert B, Petersen D, Schulz-Schaeffer W, Röther J, Heide W. [Cerebral amyloid angiopathy associated with inflammation]. Nervenarzt 2018; 89:682-91. [PMID: 29260245 DOI: 10.1007/s00115-017-0469-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cerebral amyloid angiopathy (CAA) associated with inflammation is a rare form of a potentially reversible encephalopathy in a subgroup of patients with CAA. The cerebral amyloid deposition can in isolated cases induce an inflammation predominantly of the cerebral blood vessels and a multifocal edema of the cerebral white matter. The courses can occur as monophasic, relapsing remitting and primarily progressive forms. We present seven cases with different courses of the disease and give an overview of the pathophysiology, clinical aspects and treatment of the disease with reference to the current literature. The cases presented show a very different and often difficult differential diagnostic clinical picture and all showed a significant improvement under steroid medication without signs of recurrence of the disease during the course. The recognition and early consistent treatment of inflammatory forms of CAA with and without direct inflammatory involvement of vessels can be decisive for successful treatment.
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34
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Stabile A, Di Lazzaro V, Colosimo C, Piazza F, Ferrarese C, DiFrancesco JC. Idiopathic infratentorial superficial siderosis of the central nervous system: case report and review of literature. Neurol Neurochir Pol 2017; 52:102-106. [PMID: 29122310 DOI: 10.1016/j.pjnns.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
The superficial siderosis (SS) of the central nervous system (CNS) is a rare condition characterized by a wide range of neurological manifestations directly linked to an acquired iron-mediated neurodegeneration. First described more than 100 years ago, only recently SS has been divided into two distinct entities, according to the distribution of iron deposition in the CNS: cortical superficial siderosis (cSS) and infratentorial superficial siderosis (iSS). Here we describe an adult case of iSS, with detailed clinical and radiological features. Moreover, we extensively review the literature of SS, particularly focusing on the pathogenesis, clinical-radiological classification, diagnostic algorithm and treatment options of this rare condition.
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Affiliation(s)
- Andrea Stabile
- Department of Neurology, ASST San Gerardo Hospital, Monza, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Cesare Colosimo
- Radiology and Neuroradiology Unit, Diagnostic Imaging Area, Fondazione Policlinico Universitario A. Gemelli, Institute of Radiology, School of Medicine, Catholic University, Rome, Italy
| | - Fabrizio Piazza
- Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Department of Neurology, ASST San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, ASST San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
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35
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Abstract
The chapter describes the epidemiology of cerebrovascular diseases, anatomy of the cerebral blood vessels, pathophysiology of ischemia, hypoxia, hypoxemia, anemic hypoxia, histotoxic hypoxia, carbon monoxide damage, hyperoxid brain damage and decompression sickness, and selective cell and regional vulnerability; diseases of the blood vessels including atherosclerosis, hypertensive angiopathy, small vessel disease, inflammatory vascular diseases, cerebral amyloid angiopathies, CADASIL, CARASIL and other diseases that can lead to cerebrovascular occlusion; intracranial and intraspinal aneurysms and vascular malformations; hematologic disorders that can cause cerebral infarct or hemorrhage; brain ischemic damage; and spontaneous intracranial bleeding. Within ischemic brain damage, focal cerebral ischemia, hemorrhagic infarct, brain edema, penumbra, global cerebral ischemia, venous thrombosis, lacunas and lacunar state, status cribosus, granular atrophy of the cerebral cortex, hippocampal sclerosis, vascular leukoencephalopathy Binswanger type and multi-infarct encephalopathy are discussed in detail. Cognitive impairment of vascular origin deserves an individual section.
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Affiliation(s)
- Isidro Ferrer
- Pathologic Anatomy Service, Institute of Neuropathology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.
| | - Noemi Vidal
- Pathologic Anatomy Service, Institute of Neuropathology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
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36
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Kimura A, Takemura M, Saito K, Yoshikura N, Hayashi Y, Harada N, Nishida H, Nakajima H, Inuzuka T. Comparison of cerebrospinal fluid profiles in Alzheimer's disease with multiple cerebral microbleeds and cerebral amyloid angiopathy-related inflammation. J Neurol 2016; 264:373-381. [PMID: 28000005 DOI: 10.1007/s00415-016-8362-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 01/25/2023]
Abstract
Brain magnetic resonance imaging (MRI) of patients with Alzheimer's disease (AD) sometimes reveals multiple cerebral microbleeds (CMBs) and confluent white matter hyperintensities (WMHs) similar to those observed in cerebral amyloid angiopathy-related inflammation (CAA-I). To determine whether there might be common pathophysiological mechanisms underlying the MRI findings of multiple CMBs and confluent WMHs, we investigated the cerebrospinal fluid (CSF) profiles of 38 AD, five amnestic mild cognitive impairment (MCI), and six CAA-I patients. The AD and MCI patients were divided into groups of patients with (n = 10) or without (n = 33) multiple CMBs (n ≥ 2) on T2*-gradient echo sequences of brain MRI. We compared the CSF profiles of AD and MCI patients with or without multiple CMBs, and CAA-I patients. The brain MRIs of the patients with multiple CMBs revealed severe degrees of WMHs compared with the patients without multiple CMBs. The levels of CSF anti-amyloid β autoantibody and interleukin 8, and CSF/serum albumin ratios and immunoglobulin G indexes, were significantly higher in CAA-I patients than the other groups. However, there were no significant differences in the CSF profiles of patients with or without multiple CMBs. Our study provides evidence for different pathophysiological mechanisms underlying these differential MRI findings in AD and CAA-I.
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Affiliation(s)
- Akio Kimura
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Masao Takemura
- Department of Informative Clinical Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Advanced Diagnostic System Research Laboratory, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
| | - Kuniaki Saito
- Department of Disease Control and Prevention, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
| | - Nobuaki Yoshikura
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuichi Hayashi
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Naoko Harada
- Neurology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hiroshi Nishida
- Neurology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hideto Nakajima
- Department of Internal Medicine I, Osaka Medical College, Takatsuki, Japan
| | - Takashi Inuzuka
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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37
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Affiliation(s)
- Adam MacLellan
- From the Division of Neurology, University Health Network, Toronto, Canada
| | - Ari Breiner
- From the Division of Neurology, University Health Network, Toronto, Canada
| | - David F Tang-Wai
- From the Division of Neurology, University Health Network, Toronto, Canada
| | - Leanne K Casaubon
- From the Division of Neurology, University Health Network, Toronto, Canada.
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38
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Floris G, Di Stefano F, Cherchi MV, Costa G, Marrosu F, Marrosu MG. Multiple Spontaneous Cerebral Microbleeds and Leukoencephalopathy in PSEN1-Associated Familial Alzheimer's Disease: Mirror of Cerebral Amyloid Angiopathy? J Alzheimers Dis 2016; 47:535-8. [PMID: 26401689 DOI: 10.3233/jad-150165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cerebral microbleeds (CMB) might reflect specific underlying vascular pathologies like cerebral amyloid angiopathy (CAA). In the present study we report the gradient-echo MRI pattern of two siblings with P284S PSEN1 mutation. T2* gradient-echo images of the two subjects demonstrated multiple microbleeds in lobar regions. The role and causes of CMB in sporadic Alzheimer's disease (AD) patients have not been clearly established and useful contributions could derive from familial AD studies. Furthermore, since CAA is a potential risk factor for developing adverse events in AD immunization trials, the identification in vivo of CAA through non-invasive MRI methods could be useful to monitoring side effects.
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Affiliation(s)
- Gianluca Floris
- Department of Neurology, Azienda Universitaria-Ospedaliera of Cagliari and University of Cagliari, Cagliari, Italy
| | - Francesca Di Stefano
- Department of Neurology, Azienda Universitaria-Ospedaliera of Cagliari and University of Cagliari, Cagliari, Italy
| | - Maria Valeria Cherchi
- Department of Radiology, Azienda Universitaria-Ospedaliera of Cagliari and University of Cagliari, Cagliari, Italy
| | - Gianna Costa
- Multiple Sclerosis Centre, University of Cagliari, Cagliari, Italy
| | - Francesco Marrosu
- Department of Neurology, Azienda Universitaria-Ospedaliera of Cagliari and University of Cagliari, Cagliari, Italy
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39
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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40
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Abstract
Cerebral amyloid angiopathy- related inflammation (CAA-ri) is an aggressive disease subtype of CAA with characteristic clinical and radiological findings. CAA-ri is an important diagnosis to reach in clinical practice, as patients typically respond to prompt immunosuppressive treatment. A definitive diagnosis of CAA-ri still requires a brain biopsy, and hence developing non-invasive diagnostic criteria and biomarkers for this syndrome are key priorities in the field. CAA-ri has gained additional interest for its notable similarities to amyloid-related imaging abnormalities, a complication of immunotherapy treatments in Alzheimer's disease patients. In this commentary, the current state of biomarkers research for CAA-ri and recently suggested diagnostic criteria are put into context.
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41
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Charef S, Leblanc A, Guibourg B, Quintin-Roue I, Ben Salem D, Zagnoli F. [A subacute dementia: Inflammatory cerebral amyloid angiopathy]. Rev Neurol (Paris) 2015; 171:832-40. [PMID: 26612553 DOI: 10.1016/j.neurol.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/30/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022]
Abstract
We report a case of inflammatory cerebral amyloid angiopathy (CAA) that led to rapid cognitive decline, seizures, visual hallucinations, hyperproteinorrachia and right hemispheric leukopathy. Brain biopsy gave the diagnosis of CAA. Although no inflammatory infiltrate was found in the biopsy sample, corticosteroids led to a regression of the radiological lesions without significant clinical improvement. CAA is a rare disease, defined by lesions of classical cerebral amyloid angiopathy and perivascular infiltrates in contact with the affected vessels. In cases of rapidly progressive dementia associated with leukopathy, inflammatory amyloid angiopathy should be considered as cognitive disorders may improve after immunosuppressive therapy.
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Affiliation(s)
- S Charef
- CHRU Cavale-Blanche, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - A Leblanc
- CHRU Cavale-Blanche, boulevard Tanguy-Prigent, 29200 Brest, France
| | - B Guibourg
- CHRU Morvan, 2, avenue Floch, 29200 Brest, France
| | | | - D Ben Salem
- CHRU Cavale-Blanche, boulevard Tanguy-Prigent, 29200 Brest, France
| | - F Zagnoli
- CHRU Cavale-Blanche, boulevard Tanguy-Prigent, 29200 Brest, France
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42
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Carmona-Iragui M, Fernández-Arcos A, Alcolea D, Piazza F, Morenas-Rodriguez E, Antón-Aguirre S, Sala I, Clarimon J, Dols-Icardo O, Camacho V, Sampedro F, Munuera J, Nuñez-Marin F, Lleó A, Fortea J, Gómez-Ansón B, Blesa R. Cerebrospinal Fluid Anti-Amyloid-β Autoantibodies and Amyloid PET in Cerebral Amyloid Angiopathy-Related Inflammation. J Alzheimers Dis 2015; 50:1-7. [DOI: 10.3233/jad-150614] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- María Carmona-Iragui
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Ana Fernández-Arcos
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Alcolea
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Fabrizio Piazza
- School of Medicine and Surgery, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
- The inflammatory Cerebral Amyloid Angiopathy and Alzheimer’s disease βiomarkers International Network (iCAβ), Monza, Italy
| | - Estrella Morenas-Rodriguez
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Sofía Antón-Aguirre
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Isabel Sala
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Jordi Clarimon
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Oriol Dols-Icardo
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Valle Camacho
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Frederic Sampedro
- Universitat Autònoma de Barcelona, Facultat de Medicina, Barcelona, Spain
| | - Josep Munuera
- MRI Unit Badalona Institut de Diagnòstic per la Imatge. Hospital Germans Trias i Pujol, Badalona, Spain
| | - Fidel Nuñez-Marin
- Universitat Autònoma de Barcelona, Facultat de Medicina, Barcelona, Spain
| | - Alberto Lleó
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Juan Fortea
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Beatriz Gómez-Ansón
- Universitat Autònoma de Barcelona, Facultat de Medicina, Barcelona, Spain
- Neuroradiology Unit, Department of Radiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona, Spain
| | - Rafael Blesa
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
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DiFrancesco JC, Longoni M, Piazza F. Anti-Aβ Autoantibodies in Amyloid Related Imaging Abnormalities (ARIA): Candidate Biomarker for Immunotherapy in Alzheimer's Disease and Cerebral Amyloid Angiopathy. Front Neurol 2015; 6:207. [PMID: 26441825 PMCID: PMC4585101 DOI: 10.3389/fneur.2015.00207] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/08/2015] [Indexed: 11/13/2022] Open
Abstract
Amyloid-related imaging abnormalities (ARIA) represent the major severe side effect of amyloid-beta (Aβ) immunotherapy for Alzheimer’s disease (AD). Early biomarkers of ARIA represent an important challenge to ensure safe and beneficial effects of immunotherapies, given that different promising clinical trials in prodromal and subjects at risk for AD are underway. The recent demonstration that cerebrospinal fluid (CSF) anti-Aβ autoantibodies play a key role in the development of the ARIA-like events characterizing cerebral amyloid angiopathy-related inflammation generated great interest in the field of immunotherapy. Herein, we critically review the growing body of evidence supporting the monitoring of CSF anti-Aβ autoantibody as a promising candidate biomarker for ARIA in clinical trials.
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Affiliation(s)
- Jacopo C DiFrancesco
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy
| | - Martina Longoni
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy
| | - Fabrizio Piazza
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy ; The iCAβ-ITALY Study Group of the Italian Society for the Study of Dementia (SINdem) , Monza , Italy
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Mendonça MD, Caetano A, Pinto M, Cruz e Silva V, Viana-Baptista M. Stroke-Like Episodes Heralding a Reversible Encephalopathy: Microbleeds as the Key to the Diagnosis of Cerebral Amyloid Angiopathy–Related Inflammation—A Case Report and Literature Review. J Stroke Cerebrovasc Dis 2015; 24:e245-50. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/02/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022] Open
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Crosta F, Orlandi B, De Santis F, Passalacqua G, DiFrancesco JC, Piazza F, Catalucci A, Desideri G, Marini C. Cerebral Amyloid Angiopathy-Related Inflammation: Report of a Case with Very Difficult Therapeutic Management. Case Rep Neurol Med 2015; 2015:483020. [PMID: 26351601 DOI: 10.1155/2015/483020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/20/2015] [Accepted: 07/22/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Cerebral amyloid angiopathy-related inflammation (CAA-ri) results from autoimmune response to beta-amyloid deposits in cerebral vessels. Its clinical course and complications have seldom been described in literature. Case Report. In a patient presenting with delirium and left hemiparesis the diagnosis of CAA-ri was supported by the finding of elevated anti-amyloid autoantibodies in the cerebrospinal fluid (CSF). Steroid therapy produced significant improvements in clinical and investigational assessments, but after two months, it caused Acute Respiratory Distress Syndrome. After steroid therapy discontinuation the patient presented a rapidly progressive dementia, Guillain-Barré syndrome, new cerebral ischemic lesions, and thrombosis of the right cephalic and subclavian veins that were treated with subcutaneous heparin. After a week the patient died because of brain hemorrhage. Conclusion. This case suggests caution in steroid therapy discontinuation and antithrombotic therapy administration in patients with CAA-ri. The CSF search of anti-amyloid autoantibodies could be helpful to support the diagnosis.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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DiFrancesco JC, Touat M, Caulo M, Gallucci M, Garcin B, Levy R, Uncini A, Piazza F. Recurrence of Cerebral Amyloid Angiopathy-Related Inflammation: A Report of Two Cases from the iCAβ International Network. J Alzheimers Dis 2015; 46:1071-7. [DOI: 10.3233/jad-150070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacopo C. DiFrancesco
- Department of Surgery and Translational Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
- Department of Neurology, San Gerardo Hospital, Monza, Italy
| | - Mehdi Touat
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMR 981, Predictive Biomarkers and New Therapeutic Strategies in Oncology, Gustave Roussy, Villejuif, France
| | - Massimo Caulo
- Department of Neuroscience and Imaging, University “G. d’Annunzio”, Chieti, Italy
| | - Massimo Gallucci
- Department on Neuroradiology, University of L’Aquila, L’Aquila, Italy
| | - Béatrice Garcin
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMRS, CNRS UMR, Brain & Spine Institute (ICM), Hôpital Pitié Salpêtrière, Paris, France
| | - Richard Levy
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMRS, CNRS UMR, Brain & Spine Institute (ICM), Hôpital Pitié Salpêtrière, Paris, France
| | - Antonino Uncini
- Department of Neuroscience and Imaging, University “G. d’Annunzio”, Chieti, Italy
| | - Fabrizio Piazza
- Department of Surgery and Translational Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
- The inflammatory Cerebral amyloid angiopathy and Alzheimer’s disease βiomarkers ( CAβ) International Network, Monza, Italy
- The CAβ-ITALY Study Group of the Italian Society for the study of Dementia (SINdem), Italy
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Kirshner HS, Bradshaw M. The Inflammatory Form of Cerebral Amyloid Angiopathy or “Cerebral Amyloid Angiopathy-Related Inflammation” (CAARI). Curr Neurol Neurosci Rep 2015; 15. [DOI: 10.1007/s11910-015-0572-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- N Esfahani-Bayerl
- Klinik und Poliklinik für Neurologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland,
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Fang C, Chen Y, Liao I, Lin CK. Primary Granulomatous Angiitis of the Central Nervous System With Amyloid Angiopathy: A Case Report and Literature Review. Neurologist 2015; 19:73-8. [DOI: 10.1097/nrl.0000000000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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