Novosadova O A, Semenova T N, Grigoryeva V N
Privolzhsky Research Medical University, Nizhny Novgorod, Russia.
Zh Nevrol Psikhiatr Im S S Korsakova. 2021;121(3. Vyp. 2):46-52. doi: 10.17116/jnevro202112103246.
Cerebral amyloid angiopathy (CAA) is caused by the deposition of β-amyloid in small vessels in the cerebral cortex and leptomeninges. Nowadays, CAA is recognized more often due to the development of neuroimaging technologies. The frequency of CAA increases in old age that explains its frequent association with cardiovascular diseases. Combination of CAA with atrial fibrillation (AF) causes particular difficulties in managing of the patients, since antithrombotic drugs prescribed to patients with AF mostly contraindicated in CAA because of increased risk of intracerebral hemorrhages. The article presents a case report of the patient with AF who was admitted to the stroke center with acute ischemic stroke. According to MRI, the focus of acute ischemia was small and localized in the cerebellum. This stroke was regarded as having an undetermined etiology according TOAST classification. Small-vessel occlusion subtype was not diagnosed because the TOAST criteria do not attribute an ischemic focus in the cerebellum to a lacunar stroke, while cardioembolic subtype was rejected due to a small (less than 1.5 cm in diameter) size of the focus. Probable CAA in the patient was diagnosed on the basis of the following MRI data: multiple cortical-subcortical micro-hemorrhages (T2*GRE); a single cortical focus with features of the hemorrhage at the stage of intracellular methemoglobin deposition (T1- weighted MR images); bilateral enlargement of perivascular spaces in semioval centers (FLAIR); a negative fronto-occipital gradient (T2-weighted MR images). A diagnosis of CAA was made in accordance with the 2010 Boston criteria and 2019 recommendations of the International CAA Association. The article discusses the hemorrhagic and non-hemorrhagic MRI features of CAA. Frequency of occurrence of cortical microinfarcts in CAA is discussed as well as their differences from small cardioembolic infarcts in AF. Algorithms for antithrombotic therapy for secondary prevention of ischemic stroke in patients with CAA and AF are considered.
脑淀粉样血管病（CAA）是由β-淀粉样蛋白在大脑皮层和软脑膜的小血管中沉积所致。如今，由于神经影像学技术的发展，CAA的诊断更为常见。CAA的发病率随年龄增长而增加，这解释了其与心血管疾病的频繁关联。CAA与心房颤动（AF）并存给患者的管理带来了特殊困难，因为给AF患者开的抗血栓药物在CAA中大多因脑出血风险增加而禁忌使用。本文报告了一例AF患者因急性缺血性卒中入住卒中中心的病例。根据磁共振成像（MRI），急性缺血灶较小，位于小脑。根据TOAST分类，此次卒中被认为病因不明。未诊断为小血管闭塞亚型，因为TOAST标准不将小脑的缺血灶归为腔隙性卒中，而心源性栓塞亚型也被排除，因为病灶较小（直径小于1.5厘米）。基于以下MRI数据诊断该患者可能患有CAA：多发皮质-皮质下微出血（T2*梯度回波序列）；单个皮质病灶，在细胞内高铁血红蛋白沉积阶段有出血特征（T1加权磁共振图像）；半卵圆中心血管周围间隙双侧扩大（液体衰减反转恢复序列）；额枕叶梯度阴性（T2加权磁共振图像）。根据2010年波士顿标准和国际CAA协会2019年的建议做出了CAA的诊断。本文讨论了CAA的出血性和非出血性MRI特征。还讨论了CAA中皮质微梗死的发生频率及其与AF中小的心源性栓塞性梗死的差异。考虑了CAA和AF患者缺血性卒中二级预防的抗血栓治疗算法。
