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Published on: July 28, 2018
Subcortical hemorrhage caused by cerebral amyloid angiopathy compared with hypertensive hemorrhage
Shoko Merrit Yamada1, Yusuke Tomita1, Naotaka Iwamoto1
1Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan.
Insights
This study found that surgical removal of lobular hemorrhage due to cerebral amyloid angiopathy (CAA) is feasible. However, factors like advanced age, intraventricular hemorrhage, large hematoma volume, and pre-existing dementia increase mortality risk, warranting careful consideration for surgery.
Area of Science:
- Neurology
- Neurosurgery
- Pathology
Background:
- Cerebral amyloid angiopathy (CAA) is a common cause of lobular hemorrhage, often diagnosed via imaging.
- Histological confirmation of CAA in subcortical hemorrhage is crucial for accurate diagnosis and treatment planning.
Purpose of the Study:
- To compare outcomes of surgical intervention for subcortical hemorrhage in patients with histologically confirmed cerebral amyloid angiopathy (CAA) versus non-CAA (hypertensive) causes.
- To identify factors influencing mortality and functional outcomes in CAA-related lobular hemorrhage.
Main Methods:
- Retrospective analysis of 100 craniotomy cases with subcortical hemorrhage.
- Histological examination of hematoma cavity wall tissue to differentiate between CAA and non-CAA (hypertensive) etiologies.
- Statistical comparison of demographic data, blood pressure, hematoma characteristics, and clinical outcomes (modified Rankin Scale, mortality) between the two groups.
Main Results:
- The CAA group (47 cases) was older and had lower blood pressure but larger hematoma volumes compared to the non-CAA group (53 cases).
- Functional outcomes (modified Rankin Scale at 3 months) and rebleeding rates were similar between groups.
- Mortality was higher in the CAA group, particularly in older patients with intraventricular hemorrhage and pre-existing dementia.
Conclusions:
- Surgical management of subcortical hemorrhage secondary to CAA is not contraindicated.
- High-risk factors for mortality in CAA-related hemorrhage include age over 80, intraventricular hemorrhage, hematoma volume ≥ 50 ml, and pre-existing dementia.
- Craniotomy for such patients requires careful consideration of these risk factors.
Objectives:
Most published reports on lobular hemorrhage in cerebral amyloid angiopathy (CAA) include patients diagnosed only by imaging studies. This study analyzed patients with subcortical hemorrhage histologically diagnosed as CAA or non-CAA (hypertensive).
Methods:
This is a retrospective study analyzing data from 100 craniotomy cases. Tissue of hematoma cavity wall was collected for histological investigation in hematoma removal by surgery in patients with subcortical hemorrhage. Statistical analyses of blood pressure, hematoma location and volume, outcome, and mortality was performed in CAA and non-CAA groups.
Results:
There were 47 CAA and 53 non-CAA cases, and average age was significantly older in the CAA group (p < 0.01). Blood pressure was significantly lower (p < 0.01) but hematoma volume was significantly greater (p < 0.05) in the CAA group. Rebleeding occurred in two CAA cases and one non-CAA case, but no re-operations were required. Average score of modified Rankin Scale, which is used to measure the degree of disability in patients who have had a stroke, at three months after surgery was not significantly different between the two groups (CAA: 3.94 ± 1.28, non-CAA: 3.58 ± 1.50). There were seven deaths in the CAA and six in the non-CAA group, and intraventricular hemorrhage highly complicated in the death cases in both groups. In the CAA group, average age of the fatal cases was significantly older than that of the surviving cases (p < 0.05) and six cases demonstrated dementia before onset of hemorrhage.
Conclusions:
Surgical removal of a subcortical hemorrhage caused by CAA is not contraindicated. However, age > 80 years, complication with intraventricular hemorrhage, hematoma volume ≥ 50 ml, and dementia before onset of hemorrhage contribute to high mortality, and craniotomy should be carefully considered for such patients. A limitation of this study is that comparison between CAA and non-CAA groups was performed in the patients with only surgically indicated ICH, and does not evaluate entire ICH cases with CAA. However, this study appropriately compared pathologically diagnosed CAA and non-CAA in patients with moderate to severe lobular ICH with surgical indications.
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