(Stroke. 1999;30:1291.)
© 1999 American Heart Association, Inc.
Letters to the Editor |
Surgery for Cerebral Amyloid Angiopathy–Related Hemorrhage
University of Glasgow, Department of Neuropathology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, United Kingdom
To the Editor:
The report by Izumihara et al1 adds to an existing body of evidence2 3 that neurosurgery does not have a significant adverse influence on outcome from cerebral amyloid angiopathy–related hemorrhage (CAAH). Although surgery for CAAH appears to be relatively safe, its effectiveness as in intracerebral hemorrhage in general4 remains controversial.
The authors identified 3 clinical factors (patients aged over 75 years, a parietal hematoma, and intraventricular hemorrhage) that had an adverse effect on postoperative outcome. However, Glasgow Coma Scale score, which has been shown to be one of the most powerful determinants of outcome in intracerebral hemorrhage,5 6 was unfortunately not included in this analysis. This is an important clinical factor, which in our experience with a smaller group of CAAH patients results in a poorer outcome.7 Because the report by Izumihara et al1 examines one of the largest cohorts of patients with pathologically diagnosed CAAH, it would have been clinically useful to confirm this finding for the homogeneous population in their multiple logistic regression analysis of risk factors. Nearly one third of the patients (n=12) had their operation >3 days after hemorrhage onset, suggesting that the good outcome may well have reflected good preoperative Glasgow Coma Scale scores.
Finally, possession of the apolipoprotein E (APOE) 
4 allele has
recently been recognized as an adverse prognostic factor in
intracerebral hemorrhage.8 9 It
will be interesting to examine whether this genetic determinant of
outcome applies to all types of intracerebral
hemorrhage (eg, hypertensive deep intracerebral
hemorrhage, CAAH, and thrombolytic-related
intracerebral hemorrhage). In addition, we can
as yet only speculate whether surgical intervention will have less
benefit or more benefit for an 4 carrier compared with a
noncarrier.
References
1.
Izumihara A, Ishihara T, Iwamoto N, Yamashita K, Ito
H. Postoperative outcome of 37 patients with lobar
intracerebral hemorrhage related to cerebral
amyloid angiopathy. Stroke.. 1999;30:29–33.
2.
Greene GM, Godersky JC, Biller J, Hart MN, Adams HP Jr.
Surgical experience with cerebral amyloid angiopathy.
Stroke.. 1990;21:1545–1549.
3.
Matkovic Z, Davis S, Gonzales M, Kalnins R, Masters CL.
Surgical risk of hemorrhage in cerebral amyloid angiopathy.
Stroke.. 1991;22:456–461.
4.
Hankey GJ, Hon C. Surgery for primary
intracerebral hemorrhage: is it safe and
effective? A systematic review of case series and randomized trials.
Stroke.. 1997;28:2126–2132.
5.
Portenoy RK, Lipton RB, Berger AR, Lesser ML, Lantos G.
Intracerebral haemorrhage: a model for the
prediction of outcome. J Neurol Neurosurg Psychiatry.. 1987;50:976–979.
6.
Radberg JA, Olsson JE, Radberg CT. Prognostic
parameters in spontaneous intracerebral
hematomas with special reference to anticoagulant treatment.
Stroke.. 1991;22:571–576.
7. McCarron MO, Nicoll JAR, Love S, Ironside JW. Surgical intervention, biopsy and APOE genotype in cerebral amyloid angiopathy-related haemorrhage. Br J Neurosurg. In press.
8. Alberts MJ, Graffagnino C, McClenny C, DeLong D, Strittmatter WJ, Saunders AM, Roses AD. ApoE genotype and survival from intracerebral haemorrhage. Lancet.. 1995;346:575. Letter.[Medline] [Order article via Infotrieve]
9.
McCarron MO, Muir KW, Weir CJ, AG Dyker, I Bone, JAR
Nicoll, KR Lees. The apolipoprotein E 4 allele and outcome in
cerebrovascular disease. Stroke.. 1998;29:1882–1887.
Response
Department of Neurosurgery
First Department of Pathology, Yamaguchi University School of Medicine, Yamaguchi, Japan
Key Words: amyloid • intracerebral
hemorrhage • outcome
We appreciate the comments of Drs McCarron and Nicoll regarding
our recent article. They point out that the preoperative neurological
condition in patients with intracerebral
hemorrhage has been one of the most powerful determinants of
the postoperative outcome in several previous studies and that the apoE
4 allele has recently been reported to be an adverse prognostic
factor. In our retrospective study, the preoperative neurological
condition was assessed not with the Glasgow Coma Scale, but instead
with the Japan Coma Scale in some patients, and depended on other
clinical data (demographics, medical history, and
radiographic characteristics, especially hematoma size).
Accordingly, we excluded it from the multiple logistic regression
model. We also have a great interest in the apoE 4 allele as a
risk factor for cerebral amyloid angiopathy with hemorrhage and
an adverse prognostic factor in patients with cerebral amyloid
angiopathy–related hemorrhage. On the other hand, the apoE
2 allele has recently been reported to be a risk factor for
cerebral amyloid angiopathy with hemorrhage.1
Further genetic studies might elucidate the relationship between
cerebral amyloid angiopathy and hemorrhage and a different
prognostic factor in patients with cerebral amyloid
angiopathy–related hemorrhage.
We indicated that neurosurgery could be performed relatively safely and
did not deteriorate the outcome in patients with cerebral amyloid
angiopathy–related hemorrhage. Moreover, we elucidated 3 risk
factors for an adverse postoperative outcome (parietal hematomas, age
75 years, and intraventricular
hemorrhages). Certainly, our study does not demonstrate that
neurosurgery is effective in improving the outcome. In our series,
however, 4 patients with a large hematoma had a good outcome. At
present, the diagnosis of cerebral amyloid angiopathy involves
histological examination of surgical or autopsy
specimens. Accordingly, nonsurgical treatments have been investigated
mainly in autopsy cases.2 Therefore, we consider it
difficult to compare surgical and nonsurgical treatments for patients
with cerebral amyloid angiopathy–related hemorrhage.
References
1.
Nicoll JAR, Burnett C, Love S, Graham DI, Dewar D,
Ironside JW, Stewart J, Vinters HV. High frequency of apolipoprotein E
2 allele in hemorrhage due to cerebral amyloid
angiopathy. Ann Neurol.. 1997;41:716–721.[Medline]
[Order article via Infotrieve]
2. Matkovic Z, Davis S, Gonzales M, Kalnins R, Masters CL. Surgical risk of hemorrhage in cerebral amyloid angiopathy. Stroke.. 1991;22:456–461.
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