Surgery for Cerebral Amyloid Angiopathy–Related Hemorrhage
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) ε4 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 ε4 carrier compared with a noncarrier.
- Copyright © 1999 by American Heart Association
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.
Greene GM, Godersky JC, Biller J, Hart MN, Adams HP Jr. Surgical experience with cerebral amyloid angiopathy. Stroke.. 1990;21:1545–1549.
Matkovic Z, Davis S, Gonzales M, Kalnins R, Masters CL. Surgical risk of hemorrhage in cerebral amyloid angiopathy. Stroke.. 1991;22:456–461.
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.
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.
Radberg JA, Olsson JE, Radberg CT. Prognostic parameters in spontaneous intracerebral hematomas with special reference to anticoagulant treatment. Stroke.. 1991;22:571–576.
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.
McCarron MO, Muir KW, Weir CJ, AG Dyker, I Bone, JAR Nicoll, KR Lees. The apolipoprotein E ε4 allele and outcome in cerebrovascular disease. Stroke.. 1998;29:1882–1887.
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 ε4 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 ε4 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 ε2 allele has recently been reported to be a risk factor for cerebral amyloid angiopathy with hemorrhage.R1 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.R2 Therefore, we consider it difficult to compare surgical and nonsurgical treatments for patients with cerebral amyloid angiopathy–related hemorrhage.