Cerebral Amyloid Angiopathy and Atrial Fibrillation: An up to Date Case Report

Abstract

Concurrent Cerebral Amyloid Angiopathy (CAA) and Atrial Fibrillation are becoming an increasingly common dilemma in clinical practice due to the aging population and the comorbidities associated with it. In such patients, the physician must appreciate and strike the difficult balance between the risk of ischemic strokes from atrial fibrillation on one hand, and that of intracerebral hemorrhage from coexisting CAA on the other. Anticoagulation is necessary for the former but potentially deleterious for the latter. In this case report, we present the case of a 67-year-old woman with a long history of atrial fibrillation on rivaroxaban who recently began to experience recurrent transient neurological deficits that were later diagnosed as amyloid spells related to concomitant CAA. While there is no clear-cut consensus in published literature on how to best manage these patients regarding the use of anticoagulation, it is recommended to involve a multidisciplinary team for optimal management of these patients.

Managing antithrombotic treatment in a patient with atrial fibrillation and coronary stent with transient neurological symptoms in cerebral amyloid angiopathy

“…Hemorrhagic and ischemic manifestations occur frequently in CAA and cause management dilemmas. 3 , 4 A presenting feature of CAA may be a TFNE, which may be difficult to distinguish from TIAs. CAA‐related TFNEs can be an initial sign for a high risk of future ICH.…”

Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine

“…Ischemic risk is often reduced by anticoagulants. However, patients with CAA have a high risk of intracerebral hemorrhage (ICH), worsened by anticoagulation therapy[ 1 - 3 ]. This clinical dilemma is increasingly becoming a common scenario, due to the aging of the population.…”

“…In addition to ICH, CAA can also cause ischemic events such as microinfarcts. Other important clinical manifestations of CAA may include cognitive impairments, transient neurological symptoms, and inflammatory leukoencephalopathy[ 1 , 2 ]. This clinical and pathological heterogeneity could indicate related but distinct phenotypes of CAA, reflected in different clinical syndromes[ 2 - 6 ].…”

“…Unfortunately, this scenario is becoming progressively common in clinical practice. The prevalence of CAA and AF is strongly age related[ 1 - 3 , 44 , 45 ] and increasing rapidly due to improved diagnostic procedures and aging of the global population[ 2 ]. The prevalence of moderate-to-severe CAA based on pathology and imaging was around 5% in cognitively normal elderly and up to 50% in patients with lobar ICH[ 1 ].…”

Stroke prevention in an octogenarian with atrial fibrillation, cerebral amyloid angiopathy and intracerebral hemorrhage

“…Vessels affected by CAA are predisposed to rupture, which is a major cause of spontaneous and frequently recurrent lobar cerebral hemorrhage 1 . Prevention of stroke or arterial embolism in patients with cerebral amyloid CAA, intracerebral hemorrhage (ICH) and atrial fibrillation (AF) is a therapeutic dilemma 2 . Both antiplatelet drugs (AP) and anticoagulants (AC) increase the risk of recurrent ICH, why left atrial appendage closure (LAAC) is suggested (Table 1).…”