Contemporary perspectives in cerebral amyloid angiopathy.

INTRODUCTION

Cerebral amyloid angiopathy (CAA) is a leading cause of intracranial hemorrhage and cognitive decline, resulting from amyloid-β accumulation in the walls of small cortical and leptomeningeal arterioles. While models of pathogenesis exist, the mechanisms leading to the diverse clinical manifestations of CAA remain largely unknown. There are no proven treatments, but a few clinical trials are ongoing. Meanwhile, emerging anti-amyloid-β therapies and managing patients with comorbidities including atrial fibrillation complicate clinical-practice in peopel with CAA.

AREAS COVERED: Herein, the authors provide their perspectives on CAA from initial amyloid-β deposition to clinical disease manifestations. They also discuss the emergence of iatrogenic CAA and the potential role of inflammation across CAA, questioning the concept of a single entity. Finally, the authors examine management challenges, future research horizons, and treatment directions.

EXPERT OPINION: Recent insights challenge the traditional view of a linearly progressive disease, suggesting a dynamic natural history with periods of high activity and remission. Inflammation is a topic of active investigation, with potential therapeutic relevance. Challenges remain, including the need for improved neuroimaging and fluid biomarkers for noninvasive early diagnosis. Iatrogenic CAA is a recently described amyloid-β prion disease in younger people, with known Aβ innoculation and exposure times, providing a potential 'pure' model of CAA. Research into limiting Aβ production, improving perivascular clearance, or modifying vascular remodeling and inflammation may guide novel therapeutics.