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Published on: March 7, 2019
Cerebral Amyloid Angiopathy in Stroke Medicine
Insights
Cerebral amyloid angiopathy (CAA) increases stroke and hemorrhage risks, especially with certain treatments. Tightly controlling hypertension is crucial, while caution is advised with anticoagulants, antiplatelets, and statins in affected patients.
Area of Science:
- Neurology
- Vascular Medicine
- Geriatrics
Background:
- Cerebral amyloid angiopathy (CAA) is a common degenerative vasculopathy, particularly in older adults.
- It is strongly associated with lobar intracerebral hemorrhage and sulcal bleeding.
- Prevalence increases significantly with age, affecting up to 50% of individuals in their eighth and ninth decades.
Purpose of the Study:
- To review the risks associated with cerebral amyloid angiopathy (CAA).
- To summarize the implications of CAA for stroke treatment and prevention.
Main Methods:
- A selective literature search was conducted using terms related to CAA, stroke, and hemorrhage.
- Pertinent publications were retrieved and analyzed to synthesize findings.
Main Results:
- Patients with CAA and microhemorrhages face higher risks of brain hemorrhage after thrombolytic therapy.
- Microhemorrhages are more common in cerebral hemorrhages than TIAs or infarcts, particularly with anticoagulant or antiplatelet use.
- Strict hypertension control reduces intracerebral hemorrhage (ICH) risk in probable CAA by 77%; statins may increase recurrent hemorrhage risk after lobar ICH.
Conclusions:
- Tight control of arterial hypertension is essential for patients with CAA.
- Caution is recommended when prescribing oral anticoagulants, platelet aggregation inhibitors, or statins for patients with CAA, especially after a lobar ICH.
Background:
Cerebral amyloid angiopathy (CAA) is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage. Its prevalence is estimated at 30% in the seventh decade and 50% in the eighth and ninth decades. In this review, we summarize the risks linked to CAA with respect to the treatment and prevention of stroke.
Methods:
This review is based on pertinent publications retrieved by a selective search employing the terms "amyloid cerebral angiopathy," "stroke," "intra - cerebral bleeding," and "acute stroke therapy."
Results:
Among patients given systemic lytic treatment for stroke, those who have microhemorrhages tend to have a higher risk of treatment-associated brain hemorrhage. In a meta-analysis, 70% of patients who sustained a hemorrhage after thrombolytic therapy were found to have CAA, compared to only 22% in a control population. Patients with cerebral hemorrhages have microhemorrhages more commonly than patients with transient ischemic attacks (TIA) or infarcts. This was observed among persons under treatment with vitamin K antagonists (odds ratio, 2.7) or platelet aggregation inhibitors (odds ratio, 1.7). Moreover, the apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation. Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77%. On the other hand, the use of statins after a lobar ICH increases the risk for a clinically manifest recurrent hemorrhage from 14% to 22%.
Conclusion:
In patients with CAA, arterial hypertension should be tightly controlled. On the other hand, caution should be exercised in prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, or statins for patients who have already sustained a lobar ICH.
