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18FFlutemetamol-PET Aided Classification of Cerebral Amyloid Angiopathy: A Multicenter Study
Michele Romoli1, Giulia Marinoni1, Luca Tagliabue1
1From the Neurology and Stroke Unit (M. Romoli, M.L.), Nuclear Medicine (F.M., V.M.), Diagnostic Neuroradiology Unit (P.C.), and Interventional Neuroradiology Unit (M. Ruggiero), Bufalini Hospital, AUSL Romagna, Cesena; Cerebrovascular Unit (G.M., N.R., I.C., G.B., A.B., B.S.) and Neuroradiology Unit (M.S.), Fondazione IRCCS Istituto Neurologico Carlo Besta; and Nuclear Medicine Department (L.T., A.C.), Ospedale San Paolo, Milan, Italy.
Insights
18FFlutemetamol PET imaging helps reclassify cerebral amyloid angiopathy (CAA) and arteriolosclerosis. This distinction improves long-term risk assessment for recurrent cerebrovascular events in patients with mixed pathologies.
Area of Science:
- Neurology
- Radiology
- Pathology
Background:
- Cerebral amyloid angiopathy (CAA) and arteriolosclerosis often coexist in patients with intracranial hemorrhage (ICH).
- Differentiating these pathologies is crucial for accurate risk stratification.
- Neuroimaging features of CAA and arteriolosclerosis frequently overlap.
Purpose of the Study:
- To evaluate the utility of 18Fflutemetamol PET in reclassifying patients with mixed CAA and arteriolosclerosis features.
- To assess the impact of amyloid pathology detection on long-term bleeding risk stratification.
Main Methods:
- Consecutive patients with spontaneous ICH, SAH, TFNE, or cognitive impairment and MRI showing CAA hallmarks were included.
- Patients underwent MRI with SWI and 18Fflutemetamol PET imaging.
- Long-term outcomes were compared based on PET-defined amyloid pathology status.
Main Results:
- 18FFlutemetamol PET reclassified 38 patients into the CAA/amyloid pathology group and 9 into the arteriolosclerosis-predominant group.
- The CAA/amyloid pathology group showed a higher lobar microbleed burden.
- Higher rates of composite outcomes (43.9 vs 11.1 events/100 patient-year) and ICH (36.5 vs 5.6 events/100 patient-year) were observed in the CAA/amyloid group.
Conclusions:
- 18FFlutemetamol PET imaging effectively distinguishes between CAA/amyloid pathology and arteriolosclerosis-predominant conditions in mixed cases.
- This reclassification has significant implications for predicting long-term risks of recurrent cerebrovascular events.
Objectives:
Cerebral amyloid angiopathy (CAA)-related features on neuroimaging often coexist with signs of arteriolosclerosis-small vessel disease on neuroimaging in people with intracranial hemorrhage (ICH). This study aimed at defining the value of amyloid pathology detected by 18Fflutemetamol PET in reclassification and stratification of risk of bleeding in people with mixed CAA-arteriolosclerosis features.
Methods:
We included consecutive patients admitted to 2 institutions (2018-2023) with spontaneous symptomatic ICH, subarachnoid hemorrhage (SAH), transient focal neurologic episodes (TFNE), or cognitive impairment and MRI showing CAA hallmarks. All patients underwent brain magnetic resonance imaging (MRI) with susceptibility weighted imaging and 18Fflutemetamol PET imaging and were followed up for at least 1 year. We compared cases with CAA and arteriolosclerosis + CAA features and defined long-term outcomes (composite outcome including death, ICH, ischemic stroke, SAH, TFNE) depending on PET status (CAA/amyloid pathology vs arteriolosclerosis-predominant groups).
Results:
Among 47 patients, according to PET and MRI imaging, 38 patients were reclassified in the CAA/amyloid pathology group and 9 in the arteriolosclerosis-predominant group, with similar cardiovascular risk factors but a significantly higher lobar microbleed burden for the former group. The CAA/amyloid pathology group had higher rates of composite outcome (43.9 vs 11.1 events per 100 patient-year; p = 0.039) and ICH (36.5 vs 5.6 events per 100 patient-years; p = 0.04) compared with the arteriolosclerosis-predominant group.
Discussion:
18FFlutemetamol PET imaging can help in reclassification of mixed arteriolosclerosis + CAA into CAA/amyloid pathology and arteriolosclerosis-predominant, with implications on long-term risk of recurrent events.
Classification Of Evidence:
This study provides Class IV evidence that 18Fflutemetamol PET can distinguish between CAA + arteriolosclerosis and arteriolosclerosis-predominant pathology.
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