From the Guidelines
Cerebral amyloid angiopathy (CAA) is a condition characterized by amyloid protein deposition in the walls of blood vessels in the brain, primarily affecting the elderly, and its management focuses on preventing complications and controlling symptoms, with blood pressure control being essential, as indicated by recent studies 1.
Associations of CAA
The condition is strongly associated with:
- Lobar hemorrhages
- Cognitive impairment
- Alzheimer's disease
- Older age, especially age ≥75 years
- Previous stroke or transient ischemic attack
- Intracranial aneurysm and other vascular malformations
- High systolic blood pressure
- Diabetes mellitus
- Atrial fibrillation
- Chronic pulmonary disease
- End-stage renal disease
Management of CAA
The management of CAA focuses on preventing complications and controlling symptoms, with a target blood pressure of <130/80 mmHg using medications like ACE inhibitors or calcium channel blockers, and avoiding anticoagulants and antiplatelet agents when possible, as they increase bleeding risk, as recommended by recent guidelines 1. Some key management strategies include:
- Blood pressure control
- Avoiding anticoagulants and antiplatelet agents
- Using antiepileptic drugs such as levetiracetam for seizures
- Managing cognitive symptoms with cholinesterase inhibitors like donepezil or memantine
- Regular neuroimaging with MRI for monitoring
- Counseling patients on lifestyle modifications, including avoiding head trauma, limiting alcohol consumption, and maintaining cognitive engagement
Lifestyle Modifications
Patients with CAA should be counseled on lifestyle modifications, including:
- Avoiding head trauma
- Limiting alcohol consumption
- Maintaining cognitive engagement
- Controlling hypertension
- Managing diabetes and other comorbidities
Monitoring and Follow-up
Regular monitoring and follow-up are essential to manage CAA, including:
- Regular neuroimaging with MRI
- Monitoring blood pressure and adjusting medications as needed
- Assessing cognitive function and adjusting medications as needed
- Monitoring for signs of bleeding or other complications
Overall, the management of CAA focuses on preventing complications and controlling symptoms, with a emphasis on blood pressure control, avoiding anticoagulants and antiplatelet agents, and counseling patients on lifestyle modifications, as supported by recent studies 1.
From the Research
Associations of Amyloid Angiopathy
- Cerebral amyloid angiopathy (CAA) is associated with lobar intracerebral or sulcal hemorrhage, with a prevalence of 30% in the seventh decade and 50% in the eighth and ninth decades 2
- CAA is a risk factor for treatment-associated brain hemorrhage in patients given systemic lytic treatment for stroke, with 70% of patients who sustained a hemorrhage after thrombolytic therapy found to have CAA 2
- The apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation 2
- Lewy body pathology modifies risk factors for CAA when comorbid with Alzheimer's disease pathology, with APOE ε4 increasing CAA risk in all three groups (AD, LBP, and AD-LBP) 3
- CAA is an important cause of cerebral hemorrhages, although it may also lead to ischemic infarction and dementia, and is a feature commonly associated with normal aging, Alzheimer disease, Down syndrome, and Sporadic Cerebral Amyloid Angiopathy 4
Management of Amyloid Angiopathy
- Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77% 2
- 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 2
- Surgical treatment of intracranial hemorrhage in CAA should be undertaken with caution due to the high mortality rate and potential for increased fragility of amyloid-laden blood vessels or rupture of microaneurysms 5
- Extensive cerebral amyloid angiopathy alone is sufficient to cause dementia in hereditary cerebral hemorrhage with amyloidosis-Dutch type, with implications for clinicopathological correlations in Alzheimer's disease and other dementias with cerebral amyloid angiopathy 6