Cerebral amyloid angiopathy with and without hemorrhage: evidence for different disease phenotypes

Neurology. 2015 Mar 24;84(12):1206-12. doi: 10.1212/WNL.0000000000001398. Epub 2015 Feb 25.


Objective: To gain insight into different cerebral amyloid angiopathy (CAA) phenotypes and mechanisms, we investigated cortical superficial siderosis (CSS), a new imaging marker of the disease, and its relation with APOE genotype in patients with pathologically proven CAA, who presented with and without intracerebral hemorrhage (ICH).

Methods: MRI scans of 105 patients with CAA pathologic confirmation and MRI were analyzed for CSS (focal, ≤3 sulci; disseminates, ≥4 sulci) and other imaging markers. We compared pathologic, imaging, and APOE genotype data between subjects with vs without ICH, and investigated associations between CSS and APOE genotype.

Results: Our cohort consisted of 54 patients with CAA with symptomatic lobar ICH and 51 without ICH. APOE genotype was available in 53 patients. More than 90% of pathology samples in both groups had neuritic plaques, whereas neurofibrillary tangles were more commonly present in the patients without ICH (87% vs 42%, p < 0.0001). There was a trend for patients with CAA with ICH to more commonly have APOE ε2 (48.7% vs 21.4%, p = 0.075), whereas patients without ICH were more likely to be APOE ε4 carriers (85.7% vs 53.9%, p = 0.035). Disseminated CSS was considerably commoner in patients with ICH (33.3% vs 5.9%, p < 0.0001). In logistic regression, disseminated CSS was associated with APOE ε2 (but not APOE ε4) (odds ratio 5.83; 95% confidence interval 1.49-22.82, p = 0.011).

Conclusions: This neuropathologically defined CAA cohort suggests that CSS and APOE ε2 are related to the hemorrhagic expression of the disease; APOE ε4 is enriched in nonhemorrhagic CAA. Our study emphasizes the concept of different CAA phenotypes, suggesting divergent pathophysiologic mechanisms.

MeSH terms

  • Aged
  • Apolipoprotein E2 / genetics*
  • Apolipoprotein E4 / genetics*
  • Biomarkers / metabolism
  • Cerebral Amyloid Angiopathy* / classification
  • Cerebral Amyloid Angiopathy* / genetics
  • Cerebral Amyloid Angiopathy* / metabolism
  • Cerebral Amyloid Angiopathy* / pathology
  • Cerebral Cortex / metabolism*
  • Cerebral Hemorrhage* / genetics
  • Cerebral Hemorrhage* / metabolism
  • Cerebral Hemorrhage* / pathology
  • Female
  • Genotype
  • Hemosiderosis* / genetics
  • Hemosiderosis* / metabolism
  • Hemosiderosis* / pathology
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Phenotype


  • Apolipoprotein E2
  • Apolipoprotein E4
  • Biomarkers