What is the prognosis of cerebral amyloid angiopathy (CAA) with intracranial hemorrhage?

Answer

The severity of angiopathy and fibrinoid necrosis closely correlate with the occurrence of intracranial hemorrhage (ICH). The most consistent clinical effect of cerebral amyloid angiopathy (CAA) is lobar ICH. Lobar ICH is associated with a lower mortality rate (11-32%) and a better functional outcome than are hypertensive deep ganglionic bleeds.

Of individuals with CAA-related hemorrhage, 25-40% have a recurrence, with the highest risk in the first year. Recurrent hemorrhages can occur simultaneously or several years later. They are associated with a high mortality rate (up to 40%).

In one series investigating lobar hemorrhage, the recurrence rate was reported to be 38% and the mortality rate high at 44%. Of the recurrences, 36% occurred in the same location.

Patients with a previous hemorrhage are at greater risk for subsequent hemorrhages than are those with no history. A history of hemorrhagic stroke before the index lobar hemorrhage can predict early recurrence of ICH.

Hypertension may exacerbate the tendency to suffer CAA-related hemorrhage and vice versa. Cortical petechial hemorrhage can be epileptogenic.

A higher number of ICHs at baseline on gradient-echo (GRE) magnetic resonance imaging (MRI) sequences is associated with a higher risk of future ICH, subsequent cognitive impairment, loss of independence, and death.

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Media Gallery

MRI Brain GRE 3.0 TeslaTop: Multiple scattered microbleeds in multiple vascular territories in patient with hyperhomocysteinemia and methylene-tetrahydrofolate reductase mutation. Middle: Acute parenchymal hematoma with typical appearance of right occipital microbleed and left parietal chronic microhemorrhage.Bottom: Microbleeds involving multiple lobes. Chronic hemorrhage in the left parietal lobe with typical slit-like appearance.

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Author

Ravi S Menon, MD Assistant Professor of Neurology, Georgetown University School of Medicine

Ravi S Menon, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Society of Neuroimaging, American Stroke Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Consultant, Abbott Vascular, Inc. .

Additional Contributors

Jose G Merino, MD Vascular Neurologist, Johns Hopkins Community Physicians

Jose G Merino, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Stroke Association, Asociacion Mexicana de Enfermedad Vascular Cerebral

Disclosure: Nothing to disclose.

Vladimir Hachinski, MD, MSc, DSc, FRCPC Distinguished University Professor, Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, University of Western Ontario Faculty of Medicine and Dentistry, London Health Sciences Centre, Canada

Vladimir Hachinski, MD, MSc, DSc, FRCPC is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, Ontario Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Thomas A Kent, MD Professor and Director of Stroke Research and Education, Department of Neurology, Baylor College of Medicine; Chief of Neurology, Michael E DeBakey Veterans Affairs Medical Center

Thomas A Kent, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences, Royal Society of Medicine, Sigma Xi, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: BMS/Sanofi Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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