Diagnosis of cerebral amyloid angiopathy with cerebral hemorrhage by enzyme linked immunosorbent assay (ELISA) of cystatin C in the cerebrospinal fluid

The lower level of cystatin C in cerebrospinal fluid (CSF) is one of the useful diagnostic markers of hereditary cerebral hemorrhage with amyloidosis in Iceland. We attempted to establish an assay to determine the level of cystatin C in CSF for diagnosis of CAA due to the deposition of cystatin C in CSF for diagnosis of CAA due to the deposition of cystatin C. We carried out the sandwich enzyme immunosorbent assay with the use of monoclonal mouse anti-cystatin C and polyclonal rabbit anti-cystatin C antibodies. CSF from nine cases of cerebral hemorrhage and fifty reference cases with other neurological diseases were examined. Four patients with cerebral hemorrhage showed a low level of cystatin C and clinical manifestations suggestive of CAA. Our study showed the feasibility of using ELISA for the diagnosis of cerebral amyloid angiopathy that causes cerebral hemorrhage with the deposition of cystatin C.     

No mutations in cystatin C gene in cerebral amyloid angiopathy with cystatin C deposition

To investigate the relationship between cerebral amyloid angiopathy (CAA) and cystatin C, we studied five CAA patients on whose cerebral blood vessels colocalization of cystatin C and β-protein was recognized immunohistochemically. One patient was suspected as familial CAA and the other patients were sporadic cases. Two patients had low concentration of cystatin C in their cerebrospinal fluid (CSF) as we have previously reported in CAA patients. Enzyme-linked immunosorbent assay (ELISA) revealed that cystatin C and β-protein have been included at the ratio of about 1∶100 in the crude amyloid fibrils of one patient. Using a monoclonal antibody (MAb) against cystatin C, we performed affinity chromatography and immunoblotting on her amyloid fibril fraction. Eluate showed a band with a mol wt of 14,000 and the N-terminal 14 amino acid residues of 14-kDa protein were identical with that of cystatin C. This molecular weight is not identical to that of the truncated form of cystatin C deposited in hereditary cerebral hemorrhage with amyloidosis in Iceland (HCHWA-I), but that of normal cystatin C. DNA sequence analysis of five patients whowed no point mutations in the cystatin C gene. Cystatin C and β-protein colocalization, which was recognized in amyloid lesions of CAA, suggests that cystatin C deposition may be related to β-protein deposition. We hypothesize that cystatin C deposition in sporadic cerebral amyloid angiopathy with cystatin C deposition (SCCAA) involves a different mechanism from that in HCHWA-I, which may be related to low CSF concentration of cystatin C without amino acid substitutions.     

A more efficient enzyme-linked immunosorbent assay for measurement of alpha-synuclein in cerebrospinal fluid

We describe a modification of a previously described assay for the quantification of alpha-synuclein in naive cerebrospinal fluid, which allows for a more efficient quantification of alpha-synuclein. Detection limit of the assay is 3.8 ng/ml and the assay is linear until 300 ng/ml. Inter-assay and intra-assay coefficients of variation are below 15% in a wide range of concentrations. Mean recovery of the assay is 94%. The 95% upper limit of the reference range (p95) in a group of neurological controls above the age of 45 years is 62 ng/ml. This assay can be routinely applied for quantification of alpha-synuclein in cerebrospinal fluid, but not in serum, and this may serve as a possible biomarker for alpha-synucleinopathies such as Parkinson's disease and multiple system atrophy.     

Absence of the cystatin C amyloid in the cerebral amyloid angiopathy, senile plaque, and extra-CNS amyloid deposits of aged Japanese

Amyloid protein in Icelandic patients with hereditary cerebral amyloid angiopathy (CAA) is a variant of cystatin C. Immunoreactivities of the cystatin C and other amyloid proteins were investigated in CAA and other senile amyloid deposits in the Japanese sporadic aged cases including patients with dementia of Alzheimer type, and compared with those in Icelandic hereditary CAA. Compared with positive reaction of cystatin C in Icelandic hereditary CAA, no immunoreactivity of cystatin C was found in senile amyloid deposits of the Japanese aged including CAA. Immunoreactivity of the amyloid beta protein was negative in Icelandic hereditary CAA, for which CAA and senile plaque amyloid in the Japanese senile brains were positive. Our data suggest that the cystatin C amyloid would be present only in hereditary CAA, but not in the CAA and other senile amyloid deposits of the sporadic aged cases.     

Ubiquitin in cerebral amyloid angiopathy.

Immunohistological findings in cerebral blood vessels of 4 cases with cerebral amyloid angiopathy (CAA) were compared with those of 4 Alzheimer's (AD) cases. A panel of antibodies against 2 neurofilament subunits (BF10 and RT97), a microtubule-associated protein (TAU) and ubiquitin were used. CAA cases showed a strong immunoreactivity for ubiquitin in blood vessel wall. Senile plaques (SPs) in CAA cases showed strong ubiquitin positivity but the central amyloid core was negative. AD brains showed immunoreactivity with all antibodies in SPs and neurofibrillary tangles (NFTs); blood vessels were consistently negative for ubiquitin. Control brains showed few SPs and NFTs; these were positive for ubiquitin, but blood vessels were negative. These results indicate that vascular amyloid deposition in CAA and AD may have different pathophysiological mechanisms.     

Hereditary cystatin C (γ-trace) amyloid angiopathy of the CNS causing cerebral hemorrhage

Hereditary CNS amyloid angiopathy occurring in Icelanders is the first human disorder known to be caused by deposition of cystatin C amyloid fibrils in the walls of the brain arteries leading to single or or multiple strokes with fatal outcome. One or more affected members have been verified by histological examination in 8 families containing 127 affected. These originated from the same geographic area. Abnormally low value of cystatin C found in the cerebrospinal fluid of those affected can be used to support or make diagnosis of this disease, also in asymptomatic relatives. By amino acid sequence analysis the amyloid fibrils in the patients are found to be a variant of cystatin C (gamma-trace), a major cysteine proteinase inhibitor. The variant protein has an amino acid substitution (glutamine for leucine) at position 58 in the amyloid molecule. It is postulated that a point mutation has occurred leading to production of amyloidogenic protein causing the disorder.     

Cerebrospinal fluid metallomics in cerebral amyloid angiopathy: an exploratory analysis

Journal of Neurology - Cerebral amyloid angiopathy (CAA) is associated with symptomatic intracerebral haemorrhage. Biomarkers of clinically silent bleeding events, such as cerebrospinal fluid (CSF)...     

Pathogenesis of cerebral amyloid angiopathy

Cerebral amyloid angiopathy (CAA) is the result of the deposition of an amyloidogenic protein in cortical and leptomeningeal vessels. The most common type of CAA is caused by amyloid β-protein (Aβ), which is particularly associated with Alzheimer's disease (AD). Excessive Aβ-CAA formation can be caused by several mutations in the Aβ precursor protein and presenilin genes. The origin of Aβ in CAA is likely to be neuronal, although cerebrovascular cells or the circulation cannot be excluded as a source. Despite the apparent similarity, the pathogenesis of CAA appears to differ from that of senile plaques in several aspects, including the mechanism of Aβ-induced cellular toxicity, the extent of inflammatory reaction and the role of oxidative stress. Therefore, therapeutic strategies for AD should, at least in part, also target CAA. Moreover, CAA and cerebrovascular disease (CVD) may set a lower threshold for AD-like changes to cause dementia and may even cause dementia on its own, since patients with AD and CAA and/or CVD appear to be more cognitively impaired than patients with only AD. In conclusion, the precise impact of CAA on AD or dementia remains unclear, however, its role may have been underestimated in the past, and more extensive studies of in vitro and in vivo models for CAA will be needed to elucidate the importance of CAA-specific approaches in designing intervention strategies for AD.     

淀粉样脑血管病的病理

26例淀粉样脑血管病(CAA)中,脑出血20例,蛛网膜下腔出血2例,脑梗塞3例,硬膜下血肿1例。CAA主要累及脑实质的小、中动脉的中膜及外膜以及毛细血管。本组50％病例有淀粉样脑血管病伴随血管病(CAA-AV),包括微小动脉瘤、“双桶”、葱皮样改变、类纤维素性坏死、微小动脉丛及血管周围淋巴细胞浸润。CAA往往同时伴有老年斑和神经原纤维缠结。     

Diagnosis of cerebral Whipple's disease by cerebrospinal fluid cytology

In a case of Whipple's disease the diagnosis was made by careful cytologic evaluation of the cerebrospinal fluid (CSF), identifying "Sieracki cells". A basal granuloma invaded the hypothalamus, diencephalon, and rostral parts of the brainstem. An exploration in the initial stage led to misdiagnosis as a granular cell tumor. Diagnosis was then confirmed by intestinal biopsy.     

Diagnosis of cerebral Whipple's disease by cerebrospinal fluid cytology

Summary In a case of Whipple's disease the diagnosis was made by careful cytologic evaluation of the cerebrospinal fluid (CSF), identifying Sieracki cells. A basal granuloma invaded the hypothalamus, diencephalon, and rostral parts of the brainstem. An exploration in the initial stage led to misdiagnosis as a granular cell tumor. Diagnosis was then confirmed by intestinal biopsy.

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Zusammenfassung Es wird über einen Fall mit Morbus Whipple berichtet, der bei sorgfältiger Untersuchung des Liquor cerebrospinalis durch den Nachweis von Sieracki-Zellen diagnostiziert wurde. Die Exploration eines basalen Granuloms, das in den Hypothalamus, das Diencephalon und die rostralen Anteile des Hirnstamms eingewachsen war, hatte im Frühstadium zur Fehlinterpretation eines Granularzelltumors geführt. Die Diagnose wurde schließlich durch Dünndarmbiopsie bestätigt.

     

Cerebrospinal fluid amyloid β40 is decreased in cerebral amyloid angiopathy

Cerebral amyloid angiopathy is caused by deposition of the amyloid β protein in the cerebral vasculature. In analogy to previous observations in Alzheimer disease, we hypothesized that analysis of amyloid β₄₀ and β₄₂ proteins in the cerebrospinal fluid might serve as a molecular biomarker. We observed strongly decreased cerebrospinal fluid amyloid β₄₀ (p < 0.01 vs controls or Alzheimer disease) and amyloid β₄₂ concentrations (p < 0.001 vs controls and p < 0.05 vs Alzheimer disease) in cerebral amyloid angiopathy patients. The combination of amyloid β₄₂ and total tau discriminated cerebral amyloid angiopathy from controls, with an area under the receiver operator curve of 0.98. Our data are consistent with neuropathological evidence that amyloid β₄₀ as well as amyloid β₄₂ protein are selectively trapped in the cerebral vasculature from interstitial fluid drainage pathways that otherwise transport amyloid β proteins toward the cerebrospinal fluid. Ann Neurol 2009;66:245–249     

Hereditary cerebral haemorrhage caused by cortical amyloid angiopathy

This article describes 136 patients with hereditary cerebral haemorrhages; all patients belonged to families (originally) resident in Katwijk (The Netherlands). Cases of hereditary cerebral haemorrhage have also been reported in NW-Iceland, and in the Dutch coastal village of Scheveningen. Katwijk is a Dutch fishing-village, located 20 miles north of Scheveningen. These 136 cases were encompassed in three large pedigrees, and the disorder followed an autosomal dominant mode of inheritance. No connection between the pedigrees from Iceland, Scheveningen and Katwijk has as yet been established. In our series, sclerosis with amyloid deposits could be observed in roughly a quarter of the small arteries and arterioles in the cerebral cortex and the covering arachnoid. The pathological vessels were irregularly distributed in areas and clusters, possibly leading to superficial cerebral infarcts and, secondarily, to haemorrhages. Our findings are identical with those described in patients from Scheveningen, but different from the Icelandic group. In addition to some differences in the age at onset and in the distribution of the angiopathy, it has recently been demonstrated that the amyloid in our patients is constituted by a microprotein which shows a homology to the beta-protein in Alzheimer's disease and Down's syndrome, while the amyloid in Icelandic cases is formed by an aggregation of cystatin C (gamma trace). An unexpected finding in most of our patients is the accumulation of senile plaque-like lesions in the cerebral cortex. We did not observe Alzheimer's fibrillary tangles in any of our cases.     

Immunodiagnosis of human neurocysticercosis by enzyme-linked immunosorbent assay

The diagnosis of cysticercosis by enzyme-linked immunosorbent assay using serum and CSF was assessed in 61 cases of confirmed cysticercosis and in controls. A very high level of specificity and sensitivity was found.     

Alteration of cystatin C in the cerebrospinal fluid of multiple sclerosis

The protein profiles in the cerebrospinal fluid of 10 patients with multiple sclerosis (MS), 10 patients with neuromyelitis optica (NMO), 8 inflammatory disease control patients, and 4 noninflammatory disease control patients were screened by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry. Peaks of 12.5 kDa were significantly lower in multiple sclerosis, NMO, and inflammatory disease control patients than in noninflammatory disease control patients, and 13.4 kDa peaks were higher in NMO than in inflammatory disease control patients. Further analyses demonstrated that both peaks were cystatin C. Enzyme-linked immunosorbent assay showed that the cystatin C levels tended to be lower in multiple sclerosis and NMO. Alterations of cystatin C may relate to the pathogeneses of demyelinating diseases.     

Absence of cystatin C mutation in sporadic cerebral amyloid angiopathy-related hemorrhage

In Icelandic pedigrees a cystatin C mutation, glutamine 68 (L68Q), causes autosomal dominant cerebral amyloid angiopathy-related hemorrhage (CAAH). We examined 33 patients with sporadic CAAH for this mutation. None carried L68Q and, including this report, only one of 52 published cases of sporadic CAAH has had the cystatin C mutation. Despite vascular colocalization of cystatin C with amyloid beta-protein, cystatin C L68Q is rare in sporadic CAAH.     

Imaging of amyloid burden and distribution in cerebral amyloid angiopathy

OBJECTIVE: Cerebrovascular deposition of beta-amyloid (cerebral amyloid angiopathy [CAA]) is a major cause of hemorrhagic stroke and a likely contributor to vascular cognitive impairment. We evaluated positron emission tomographic imaging with the beta-amyloid-binding compound Pittsburgh Compound B (PiB) as a potential noninvasive method for detection of CAA. We hypothesized that amyloid deposition would be observed with PiB in CAA, and based on the occipital predilection of CAA pathology and associated hemorrhages, that specific PiB retention would be disproportionately greater in occipital lobes. METHODS: We compared specific cortical PiB retention in 6 nondemented subjects diagnosed with probable CAA with 15 healthy control subjects and 9 patients with probable Alzheimer's disease (AD). RESULTS: All CAA and AD subjects were PiB-positive, both by distribution volume ratio measurements and by visual inspection of positron emission tomographic images. Global cortical PiB retention was significantly increased in CAA (distribution volume ratio 1.18 +/- 0.06) relative to healthy control subjects (1.04 +/- 0.10; p = 0.0009), but was lower in CAA than in AD subjects (1.41 +/- 0.17; p = 0.002). The occipital-to-global PiB ratio, however, was significantly greater in CAA than in AD subjects (0.99 +/- 0.07 vs 0.86 +/- 0.05; p = 0.003). INTERPRETATION: We conclude that PiB-positron emission tomography can detect cerebrovascular beta-amyloid and may serve as a method for identifying the extent of CAA in living subjects.     

The incidence of cerebral amyloid angiopathy in Alzheimer's disease.

The incidence and forms of cerebral amyloid angiopathy were studied in 15 cases of Alzheimer's disease using Congo red staining and polarization. Thirteen cases showed slight to severe involvement; two contained no amyloid vascular degeneration. There was a correlation between the presence of amyloid-rich plaques and cerebral amyloid angiopathy (especially the plaque-like angiopathy) but no correlation with "amyloid-poor" senile plaques or Alzheimer's neurofibrillary degeneration.     

Leukoencephalopathy in diffuse hemorrhagic cerebral amyloid angiopathy

We have studied 12 patients with diffuse hemorrhagic cerebral amyloid angiopathy clinically and at postmortem examination. The brains in 8 patients had diffuse bilateral loss of myelin in the hemispheric white matter sparing the U fibers, corpus callosum, and internal capsules. The periventricular areas were predominantly affected. Microscopic examination of the white matter showed an association with subacute or chronic edematous lesions: spongiosis, swollen oligodendroglia, widening of the perivascular spaces with edema fluid or siderophages, hyalinization of the blood vessel walls, incomplete myelin loss, and astrocytic gliosis. Three of 8 autopsied patients had undergone computed tomographic examination, which showed bilateral hypodensity of the hemispheric white matter. The brains of 4 patients with illnesses of shorter duration showed only discrete but similar lesions in the centrum semiovale. These white matter changes are similar to those observed in Binswanger's subcortical encephalopathy. We suggest that a common mechanism of hypoperfusion of the distal white matter causes the leukoencephalopathy.