Does a patient with cerebral amyloid angiopathy (CAA) require prophylaxis?

From the Guidelines

Patients with amyloid angiopathy do not require routine prophylaxis, but anticoagulation and antiplatelet therapy should be avoided or used with caution due to the increased risk of intracerebral hemorrhage. When considering prophylaxis for patients with amyloid angiopathy, it is essential to weigh the risks and benefits, particularly in those with conditions like atrial fibrillation, where anticoagulation may be necessary 1.

Key Considerations

• The balance of net benefit from long-term oral anticoagulation might be more favorable in those with deep ICH or without neuroimaging evidence of cerebral amyloid angiopathy 1.
• Clinicians should aim to estimate the risk of recurrent ICH and the risk of ischemic stroke in ICH survivors with AF 1.
• Blood pressure control is crucial, with a target of <130/80 mmHg recommended to reduce hemorrhage risk.

Management Approach

• Management should focus on controlling modifiable risk factors like hypertension, avoiding head trauma, and regular neurological monitoring.
• There are currently no FDA-approved medications specifically for preventing CAA progression, though clinical trials are investigating potential therapies targeting amyloid deposition.
• The optimal timing of anticoagulation after ICH is not known, but should be delayed beyond the acute phase (approximately 48 h) and probably for at least approximately 4 weeks 1.

From the Research

Patient Management

The management of patients with cerebral amyloid angiopathy (CAA) is complex and requires careful consideration of the risks and benefits of anticoagulation therapy.

• Patients with CAA and atrial fibrillation (AF) are at increased risk of both ischemic and hemorrhagic stroke 2.
• The use of anticoagulation therapy in these patients should be individualized, taking into account the patient's risk of ischemic stroke, as well as their risk of hemorrhagic stroke 3.
• The presence of cortical microbleeds (CMBs), cortical superficial siderosis (cSS), or convexal subarachnoid hemorrhage (cSAH) may indicate a higher risk of hemorrhagic stroke and should be considered when making decisions about anticoagulation therapy 2.

Risk Assessment

The risk of ischemic stroke in patients with AF can be quantified using the CHA2DS2-VASc score, while the risk of hemorrhagic stroke can be assessed using imaging biomarkers such as CMBs, cSS, and cSAH 2, 4.

• Patients with CAA and a history of lobar intracerebral hemorrhage (ICH) are at increased risk of recurrent hemorrhagic stroke, with an annual recurrence rate of 8.9% 2.
• The presence of CMBs is associated with a dose-dependent risk of ICH, which rises with the use of oral anticoagulants (OACs) 2.

Treatment Strategies

The treatment of patients with CAA should be tailored to their individual risk profile and may involve the use of anticoagulation therapy, antiplatelet therapy, or other interventions such as left atrial appendage closure 5.

• In patients with CAA and AF, antithrombotic therapy should be avoided in those with predominant ICH, cSS, or cSAH features, while those with ≥2 CMBs require in-depth risk-benefit analysis using a multidisciplinary approach 2.
• Emerging avenues for potential future interventions in CAA include the development of therapies aimed at reducing the risk of hemorrhagic stroke, as well as the use of immunosuppressive treatment for cerebral amyloid angiopathy-related inflammation 5.