Stroke prevention approaches for patients with cerebral amyloid angiopathy

With an ageing population, clinicians are more frequently encountering patients with atrial fibrillation (AF) who are also at risk of intracerebral haemorrhage due to cerebral amyloid angiopathy.

Cerebral amyloid angiopathy (CAA) is a condition common among elderly patients that is characterised by β-amyloid deposition in small blood vessels in the brain, making them more fragile.

Whilst this is often asymptomatic for most patients, CAA increases the risk of a brain haemorrhage when combined with other risk factors, such as blood pressure fluctuations or the use of anticoagulants.

The presence and severity of CAA should be considered when deciding on the best stroke-prevention treatment for patients with AF and a recent lobar intracerebral haemorrhage, as they may benefit from anticoagulant treatment.

In conversation with Dr Andreas Charidimou

Given the current scarcity of randomised trial data to guide stroke prevention strategies, Dr Lucio D’Anna, a consultant in stroke medicine at Imperial College Healthcare NHS Trust, discusses the use of pharmacologic and non-pharmacologic approaches, such as left atrial appendage occlusion, to decrease stroke risk in this challenging patient group with Dr Andreas Charidimou, an instructor in neurology at Boston University Medical Center.

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Take home messages

After discussing with Dr Charidimou, Dr D’Anna summarises the take home messages as the following:

1. Given limited data from randomised trials regarding anticoagulation in intracerebral haemorrhage patients with probable cerebral amyloid angiopathy and atrial fibrillation, currently the best choice for patients is to enrol them into randomised clinical trials such as PRESTIGE-AF.
2. There is not enough evidence to support the conclusion that left atrial appendage occlusion is safe and effective in intracerebral haemorrhage patients with cerebral amyloid angiopathy and atrial fibrillation.
3. The risk of thromboembolism in patients with atrial fibrillation after an intracerebral haemorrhage should be weighted carefully even if the patient has imaging markers of cerebral amyloid angiopathy such as cerebral microbleeds, cortical superficial siderosis and white matter hyperintensities.

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Use the following guide to direct yourself to different sections of the conversation:

00:00 – introduction

01:45 – what is cerebral amyloid angiopathy (CAA)?

03:35 – why is it important to consider CAA in patient management?

05:03 – what are the signs and symptoms of CAA?

06:34 – what are the main neuroimaging features that can be related to higher risk of future intracerebral haemorrhage?

09:20 – what are the updates recently made to the Boston criteria for CAA diagnosis?

13:21 – what is the risk of an ischaemic stroke for a patient with atrial fibrillation and CAA who recently suffered an intracerebral haemorrhage?

15:17 – what is the evidence to start anticoagulants in these patients?

16:55 – when do you think a patient with atrial fibrillation and CAA would be unsuitable for anticoagulation?

18:17 – what are observational studies telling us about the risk of vascular events in patients with CAA?

20:05 – how does CAA affect the risk of a recurrent haemorrhage for patients who have had a lobar intracerebral haemorrhage?

21:30 – and how about for deep intracerebral haemorrhages?

22:45 – what is the role of microbleeds in the risk of intracerebral haemorrhages for patients with/without CAA?

25:26 – should we enrol patients with a lobar intracerebral haemorrhage and CAA into an anticoagulant clinical trial?

27:38 – are there particular patients you wouldn’t recommend participating in one of these trials?

28:58 – do you think left atrial appendage occlusion could be a better option for stroke prevention for these patients?

30:07 – do you routinely send these patients for left atrial appendage occlusion?

31:14 – summarise what you currently think is the best management for patients with intracerebral haemorrhage and CAA?

33:04 – take home messages