Cerebral Amyloid Angiopathy: Diagnostic Clarification via Biopsy and Amyloid Staining after Intracranial Hematoma Evacuation
Valeria Fagundo1, Nicole Platti1, Alena Makarova1, Lorraine Bermudez Rivera2, David Rose1
1University of South Florida, 2University of Central Florida
Objective:
To highlight the diagnostic utility and treatment implications of amyloid staining for patients with intracerebral hemorrhage (ICH) undergoing surgical evacuation.
Background:
Cerebral amyloid angiopathy (CAA) is a degenerative disorder characterized by the deposition of β-amyloid peptide in the cortical and leptomeningeal arteries and capillaries. The incidence of CAA increases with age, accounting for 5–20% of non-traumatic spontaneous ICH in the elderly. Diagnosing CAA is essential for assessing the risk of ICH recurrence. It is also necessary for guiding treatment decisions, as the use of anticoagulation, thrombolytics, and antiplatelets increase the risk of hemorrhage in vulnerable vessels. According to the Boston criteria, a definite diagnosis of CAA-related ICH requires evidence of lobar or cortico-subcortical hemorrhage and consistent pathology on postmortem examination. A diagnosis of probable CAA with supporting pathology can be made with a biopsy of the hematoma or cerebral cortex.
Design/Methods:
Case report
Results:
We report a case of a woman in her 80s with 12-18 months of memory loss presenting as a stroke alert for acute encephalopathy and global aphasia. NIH Stroke Scale was 10. CT head showed large left temporal lobar hemorrhage with midline shift. Blood pressure was mildly elevated at 140s-160s/50s-70s. She was not using antiplatelet medications or anticoagulants. There were no microhemorrhages or definitive superficial siderosis on MRI SWI sequencing. Due to clinical worsening, the patient underwent hemi-craniotomy with hematoma evacuation, and specimens were sent for pathology review. A Congo red stain was positive for amyloid deposition in the blood vessel walls.
Conclusions:
In cases of lobar hemorrhage requiring hematoma evacuation, biopsy with amyloid staining can provide diagnostic clarity and guide further management. This is especially useful in situations of competing etiologies like hypertension and when neuroimaging does not have additional supportive features of CAA.
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