What is the management of amyloid angiopathy?

From the Guidelines

The management of amyloid angiopathy should focus on preventing bleeding and managing symptoms, with careful control of blood pressure and avoidance of anticoagulants and antiplatelet medications when possible. The primary goal in managing amyloid angiopathy is to reduce the risk of bleeding, as the condition involves the accumulation of amyloid deposits in blood vessel walls, making them fragile and prone to rupture. Key aspects of management include:

• Careful control of blood pressure, typically maintaining systolic pressure below 130 mmHg using standard antihypertensive medications like ACE inhibitors, ARBs, or calcium channel blockers.
• Avoidance of anticoagulants and antiplatelet medications, as they increase the risk of bleeding, although oral anticoagulation is recommended in patients with clinical atrial fibrillation at elevated thromboembolic risk to prevent ischemic stroke and thromboembolism 1.
• Management of symptoms such as seizures, cognitive decline, and inflammation, which may require the use of anticonvulsants, cholinesterase inhibitors, memantine, or corticosteroids.
• Regular neurological monitoring with follow-up MRI scans every 6-12 months to track disease progression.
• Counseling patients about avoiding head trauma and activities with high risk of falls. It is essential to note that the management approach is largely supportive, as there is currently no specific treatment to remove amyloid deposits from blood vessels. In patients with atrial fibrillation, identification and management of risk factors and comorbidities is recommended as an integral part of AF care 1, which may also be applicable to patients with amyloid angiopathy. However, the primary focus should be on preventing bleeding and managing symptoms, rather than solely on managing atrial fibrillation or other comorbidities.

From the Research

Management of Amyloid Angiopathy

The management of amyloid angiopathy involves several strategies to reduce the risk of intracerebral hemorrhage and other complications.

• Strict control of arterial hypertension is crucial, as it can lower the risk of intracerebral hemorrhage by 77% in persons with probable cerebral amyloid angiopathy (CAA) 2.
• Caution should be exercised when prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, as they can increase the risk of treatment-associated brain hemorrhage 2.
• The use of statins after a lobar intracerebral hemorrhage should also be approached with caution, as it can increase the risk of recurrent hemorrhage from 14% to 22% 2.

Treatment and Prevention

The treatment and prevention of stroke in patients with CAA require careful consideration of the risks and benefits of different therapies.

• Systemic lytic treatment for stroke should be used with caution in patients with CAA, as they are at higher risk of treatment-associated brain hemorrhage 2.
• The apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage under oral anticoagulation, and this should be taken into account when managing patients with CAA 2.

Novel Therapies

Research is ongoing to develop novel therapies for the treatment and prevention of CAA.

• Theranostic nanovehicles (TNVs) have been developed to target cerebrovascular amyloid deposits and provide magnetic resonance imaging (MRI) contrast for early detection of CAA 3.
• These TNVs have shown promise in reducing pro-inflammatory cytokine production by the amyloid beta-challenged blood-brain barrier endothelium and may offer a new approach to the management of CAA 3.