Erfan Bashar
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Cerebral Amyloid Angiopathy — Clinical Presentation

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Educational scope notice: This is a study note for medical students, not medical advice, diagnosis, or treatment guidance. Clinical management should follow local protocols and current guidelines.

Amyloid angiopathy presents in older adults with bleeding in cortical territories, the opposite distribution to hypertensive small-vessel disease. When an older patient shows lobar microbleeds or a peripheral haemorrhage without a clear hypertensive mechanism, amyloid angiopathy belongs at the top of the differential.

Haemorrhagic manifestations

  • Lobar intracerebral haemorrhage is the most dramatic presentation: bleeding in peripheral regions such as the frontal, parietal, or occipital lobes rather than the basal ganglia or brainstem.
  • Lobar microbleeds are the earliest sign. They are invisible on CT and visible only on blood-sensitive MRI sequences, often multiple and all in lobar positions.
  • Cortical superficial siderosis is hemosiderin deposited along the brain surface from prior small surface haemorrhages, visible on susceptibility-weighted imaging.
  • Transient focal neurological episodes are brief, recurrent, stereotyped spells that can resemble transient ischaemic attacks. They occur in a subset of patients, often alongside cortical superficial siderosis, and are a recognised presenting syndrome in the current diagnostic criteria.

Non-haemorrhagic manifestations

  • White matter hyperintensities on FLAIR reflect chronic ischaemia and vascular injury, overlapping in appearance with hypertensive small-vessel change.
  • Enlarged perivascular spaces, particularly in the centrum semiovale, reflect impaired perivascular amyloid drainage.
  • Progressive cognitive decline can dominate the picture, often mixed with Alzheimer pathology given how frequently the two conditions coexist.

An older patient with a lobar haemorrhage, multiple lobar microbleeds, no deep haemorrhagic lesions, and cognitive or white matter change fits amyloid angiopathy until another cause is established.

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