By Matthew E. Fink, MD

Professor and Chairman, Department of Neurology, Weill Cornell Medical College, Neurologist-in-Chief, New York Presbyterian Hospital

Dr. Fink reports no financial relationships relevant to this field of study.

Source: Beitzke M, et al. Contribution of convexal subarachnoid hemorrhage to disease progression in cerebral amyloid angiopathy. Stroke 2015;46:1533-1540.

Cerebral amyloid angiopathy is emerging as a major cause of spontaneous intracerebral hemorrhage in the elderly. The risk of intracerebral hemorrhage in these patients seems to be related to the number of factors — lobar microbleeds, previous clinical episodes of hemorrhage, and the extent of leukoaraiosis. It has also been postulated that cortical superficial siderosis may be an indicator of increased risk for future intracerebral hemorrhage in this elderly population. The authors of this study undertook a careful review of all of the patients in their database over a 9-year period who had spontaneous convexal subarachnoid hemorrhage, and they performed a careful longitudinal analysis of clinical and neuroimaging data.

Of 38 cases with convexal subarachnoid hemorrhage (mean age, 77 years), 29 (76%) had imaging features of cerebral amyloid angiopathy on baseline imaging, and 26 (68%) had convexal superficial siderosis. Sixteen subjects who underwent post-contrast MRI had extravasation of gadolinium at the site of the acute subarachnoid hemorrhage. After a mean follow-up of 24 months, 39% of the patients had experienced recurrent convexal subarachnoid hemorrhage events, and 37% suffered lobar intracerebral hemorrhage. Of the new intracerebral hemorrhage events, most occurred at sites of previous convexal subarachnoid hemorrhage. In one autopsy case, leakage was demonstrated in meningeal vessels on pathologic examination. The authors concluded that in cerebral amyloid angiopathy, leakage of meningeal vessels is a major cause for recurrent bleeding, which may lead to propagation and frank intracerebral lobar hemorrhage.