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Transient Focal Neurological Events in Cerebral Amyloid Angiopathy and the Long-term Risk of Intracerebral Hemorrhage and DeathA Systematic Review and Meta-analysis

Educational Objective
To determine the risk factors of lobar intracerebral hemorrhage and death after a transient focal neurologic episode in patients with cerebral amyloid angiopathy.
1 Credit CME
Key Points

Question  What are the risk factors for lobar intracerebral hemorrhage and death after a transient focal neurological episode (TFNE) in cerebral amyloid angiopathy?

Findings  In this pooled analysis of a systematic review and individual participant meta-analysis and a hospital-based cohort including 248 adults with cerebral amyloid angiopathy (CAA)–associated TFNEs, motor TFNEs and antithrombotics use were associated with an increase in risk of lobar intracerebral hemorrhage. Intracerebral hemorrhage and cortical superficial siderosis were associated with higher mortality rates.

Meaning  The findings from this study show that antithrombotics use after a TFNE and motor TFNEs may be 2 novel hemorrhage risk markers in CAA; this work may help stratify hemorrhage and risk of death in patients with CAA.


Importance  Transient focal neurological episodes (TFNEs) are a frequently overlooked presentation of cerebral amyloid angiopathy (CAA), a condition with prognostic implications that are still not well described.

Objective  To perform a systematic review and meta-analysis to examine the factors associated with incident lobar intracerebral hemorrhage (ICH) and death in patients with CAA presenting with TFNEs.

Data Sources  A systematic review and individual participant meta-analysis including (1) a hospital-based cohort and (2) the results obtained from a systematic search performed in MEDLINE and Embase completed in December 2019.

Study Selection  Included studies were observational reports of TFNEs. Patient-level clinical, imaging, and prognostic data were required for inclusion. For aggregate data studies, patient-level data were requested. Disagreements were resolved by consensus.

Data Extraction and Synthesis  Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines by 4 independent reviewers. The quality of reports was determined based on the modified Pearson Case Report Quality Scale.

Main Outcomes and Measures  The clinical characteristics of TFNEs, neuroimaging features, and use of antithrombotics during follow-up were considered exposures. The predefined main outcomes were lobar ICH and risk of death during follow-up.

Results  Forty-two studies and 222 CAA-associated TFNE cases were included from the initial 1612 records produced by the systematic search; 26 additional patients (11 men [42.3%]; mean [SD] age, 77 [8] years) were provided by the hospital-based cohort. A total of 108 TFNEs (43.5%) consisted of motor symptoms. Convexity subarachnoid hemorrhage and cortical superficial siderosis were detected in 193 individuals (77.8%) and 156 individuals (62.9%) in the systematic search and hospital-based cohort, respectively. Follow-up duration could be obtained in 185 patients (median duration, 1 year [IQR, 0.8-2.5 years]). During follow-up, symptomatic lobar ICH occurred in 76 patients (39.4%). Motor symptoms (odds ratio, 2.08 [95% CI, 1.16-3.70]) at baseline and antithrombotic use during follow-up (odds ratio, 3.61 [95% CI, 1.67-7.84]) were associated with an increase in risk of lobar ICH. A total of 31 patients (16.5%) died during follow-up; lobar ICH during follow-up and cortical superficial siderosis were the main risk factors for death (odds ratio, 3.01 [95% CI, 1.36-6.69]; odds ratio, 3.20 [95% CI, 1.16-8.91], respectively).

Conclusions and Relevance  Patients presenting with CAA-associated TFNEs are at high risk of lobar ICH and death. Motor TFNEs and use of antithrombotics after a TFNE, in many cases because of misdiagnosis, are risk factors for ICH, and therefore accurate diagnosis and distinguishing this condition from transient ischemic attacks is critical.

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Article Information

Accepted for Publication: September 11, 2021.

Published Online: November 15, 2021. doi:10.1001/jamaneurol.2021.3989

Corresponding Author: Jorge Rodríguez-Pardo, MD, PhD, Department of Neurology, Hospital La Paz Institute for Health Research–IdiPAZ (La Paz University Hospital–Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain (jrpardodedonlebun@salud.madrid.org).

Author Contributions: Drs Rodríguez-Pardo and Sánchez-Caro had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sanchez-Caro, Fuentes, Diez-Tejedor, Rodríguez-Pardo.

Acquisition, analysis, or interpretation of data: Sanchez-Caro, de Lorenzo, de Celis Ruiz, Barguilla, Calviere, Raposo, Galiano Blancart, Rodríguez-Pardo.

Drafting of the manuscript: Sanchez-Caro, Rodríguez-Pardo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sanchez-Caro.

Administrative, technical, or material support: Sanchez-Caro, de Lorenzo, Barguilla.

Supervision: Sanchez-Caro, Fuentes, Diez-Tejedor, Rodríguez-Pardo.

Conflict of Interest Disclosures: Dr Calviere reported nonfinancial support from Pfizer and Boehringer Ingelheim and personal fees from Pfizer–Bristol Myers Squibb outside the submitted work. No other disclosures were reported.

Additional Contributions: This study was promoted by the INVICTUS-Plus Spanish Network of the ISCIII (RD16/0019/0005) and the European Regional Development Fund. These networks facilitated the cooperation between investigators but did not fund any aspect of the study. We appreciate the support of Morote Traducciones SL for their editing assistance.

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