Silent ischemic infarcts are associated with hemorrhage burden in cerebral amyloid angiopathy

Abstract

Background: Neuropathologic studies suggest an association between cerebral amyloid angiopathy (CAA) and small ischemic infarctions as well as hemorrhages. We examined the prevalence and associated risk factors for infarcts detected by diffusion-weighted imaging (DWI).

Methods: We performed retrospective analysis of MR images from 78 subjects with a diagnosis of probable CAA and a similar aged group of 55 subjects with Alzheimer disease or mild cognitive impairment (AD/MCI) for comparison. DWI and apparent diffusion coefficient (ADC) maps were inspected for acute or subacute infarcts. We also examined the association between DWI lesions and demographic variables, conventional vascular risk factors, and radiographic markers of CAA severity such as number of hemorrhages on gradient-echo MRI and volume of T2-hyperintense white matter lesions.

Results: Twelve of 78 subjects with CAA (15%) had a total of 17 DWI-hyperintense lesions consistent with subacute cerebral infarctions vs 0 of 55 subjects with AD/MCI (p = 0.001). The DWI lesions were located primarily in cortex and subcortical white matter. CAA subjects with DWI lesions had a higher median number of total hemorrhages (22 vs 4, p = 0.025) and no difference in white matter hyperintensity volume or conventional vascular risk factors compared to subjects with CAA without lesions.

Conclusions: MRI evidence of small subacute infarcts is present in a substantial proportion of living patients with advanced cerebral amyloid angiopathy (CAA). The presence of these lesions is associated with a higher burden of hemorrhages, but not with conventional vascular risk factors. This suggests that advanced CAA predisposes to ischemic infarction as well as intracerebral hemorrhage.

Figure Representative MR images of silent ischemic infarcts in two patients with cerebral amyloid angiopathy Each row of panels corresponds to axial diffusion-weighted imaging (DWI) (A and D), apparent diffusion coefficient (B and E), and fluid-attenuated inversion recovery (C and F) sequences from a single MRI scan. Panels A–C were obtained 3 months after a right frontal intracerebral hemorrhage in a 57-year-old man. Panels D–F were obtained 2 days after a right frontal intracerebral hemorrhage (asterisk in panel D) in a 70-year-old man. The arrows point to DWI-hyperintense lesions identified as subacute ischemic infarcts.