Hampshire Hospital Foundation Trust, Department of Elderly Care, Royal Hampshire County Hospital, Winchester, Hampshire, UK.
Age Ageing. 2021 Feb 26;50(2):347-355. doi: 10.1093/ageing/afaa275.
Cerebral amyloid angiopathy (CAA) most commonly presents with lobar intracerebral haemorrhage, though also with transient focal neurological episodes, cognitive impairment, as an incidental finding and rarely acutely or subacutely in patients developing an immune response to amyloid. Convexity subarachnoid haemorrhage, cortical superficial siderosis and lobar cerebral microbleeds are the other signature imaging features. The main implications of a diagnosis are the risk of intracerebral haemorrhage and frequent co-existence of antithrombotic indications. The risk of intracerebral haemorrhage varies by phenotype, being highest in patients with transient focal neurological episodes and lowest in patients with isolated microbleeds. There is only one relevant randomised controlled trial to CAA patients with antithrombotic indications: RESTART showed that in patients presenting with intracerebral haemorrhage while taking antiplatelets, restarting treatment appeared to reduce recurrent intracerebral haemorrhage and improve outcomes. Observational and indirect data are reviewed relevant to other scenarios where there are antithrombotic indications. In patients with a microbleed-only phenotype, the risk of ischaemic stroke exceeds the risk of intracerebral haemorrhage at all cerebral microbleed burdens. In patients with atrial fibrillation (AF), left atrial appendage occlusion, where device closure excludes the left atrial appendage from the circulation, can be considered where the risk of anticoagulation seems prohibitive. Ongoing trials are testing the role of direct oral anticoagulant (DOACs) and left atrial appendage occlusion in patients with intracerebral haemorrhage/AF but in the interim, treatment decisions will need to be individualised and remain difficult.
脑淀粉样血管病（Cerebral amyloid angiopathy，CAA）最常表现为脑叶颅内出血，但也可出现短暂性局灶性神经功能障碍、认知障碍、偶然发现，以及在对淀粉样蛋白产生免疫反应的患者中很少出现急性或亚急性发作。大脑凸面蛛网膜下腔出血、皮质浅表铁质沉着症和脑叶微出血是其他特征性影像学表现。诊断的主要意义是颅内出血风险和频繁并存的抗血栓治疗指征。颅内出血风险因表型而异，在出现短暂性局灶性神经功能障碍的患者中最高，在仅存在孤立性微出血的患者中最低。唯一一项与 CAA 患者抗血栓治疗指征相关的随机对照试验是 RESTART 研究：该研究显示，在服用抗血小板药物的患者中出现颅内出血时，重新开始治疗似乎可降低复发性颅内出血风险并改善结局。本文回顾了与其他存在抗血栓治疗指征的情况下相关的观察性和间接数据。在仅存在微出血表型的患者中，在所有脑微出血负荷下，缺血性卒中风险超过颅内出血风险。在患有心房颤动（Atrial Fibrillation，AF）的患者中，如果抗凝治疗风险似乎不可行，可考虑左心耳封堵术，即将装置关闭以防止左心耳血流进入循环。正在进行的试验正在测试直接口服抗凝剂（Direct Oral Anticoagulants，DOACs）和左心耳封堵术在颅内出血/AF 患者中的作用，但在此期间，治疗决策需要个体化，仍然存在困难。
