<International Circulation>： My last question is about cerebral amyloid angiopathy (CAA)， a major cause of lobar ICH and cognitive decline in the elderly. What is the status of clinical studies in this patient group at the moment? How are patients with CAA being managed? What can we do with patients with amyloid angiopathy?

　　《国际循环网》：最后一个问题是关于脑血管淀粉样变性，是老年人脑叶ICH和认知功能降低的主要原因。目前关于这些患者的临床研究现状如何？如何管理脑血管淀粉样变性的患者？我们能为这些患者做些什么？

　Prof.Greenberg:  Well， especially true of the hemorrhaging field in general， is that no treatment has yet been established as an acute intervention with that approves outcome. We know that overall intensive care improves outcomes because there are reasonably good studies that show that admission to a neurological ICU results in better outcome after a hemorrhagic stroke than admission to a general floor but we don’t know which of the things that a neurological ICU offers results in better outcomes or if it’s just the result of a bunch of small benefits all put together that lead to a larger， more measurable benefits. Also， what’s true for hemorrhaging in general is also true for amyloid angiopathy. There have not been any acute treatments that have been proven to be more effective for a particular type of hemorrhage， for example amyloid angiopathy as opposed to hypertensive hemorrhage. We are awaiting several major trials， in particular the INTERACTⅡ(Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage) study. They will be presented， but unfortunately not at ISC. The results are not ready yet to be made public but involve tighter blood pressure control and intracerebral hemorrhage. There is also the STICHⅡ(Surgical Trial in Lobar Intracerebral Haemorrhage) study looking at early surgery on hemorrhaging particularly near the brain’s surface. I think that one important point that is an area of confusion for a lot of institutions is whether it is safe for a person expected to have amyloid angiopathy hemorrhaging to remove it. There are still people that are concerned that if you cut across the amyloid-related hemorrhage that there will be bleeding because the vessels are friable. In general experience it has not been born out the concern in the STICHⅠstudy that the one sub-group of people who at least appeared to have some benefit were those with superficial hemorrhaging， many of which were due to amyloid angiopathy. This is really the motivation behind focusing on this kind of hemorrhages in the STICHⅡ study and the fact that there are at least promising results from the STICHⅠstudy is a pretty good argument for me， that although we don’t know what surgery is good or not good that it is safe to consider people with amyloid angiopathy (for surgery). One other point I would add is that for people with hemorrhagic stroke or really for those with stroke in general is that although we hope to improve our acute stroke treatment， but if we could have one wish it would be that we can prevent it before it occurs. We will certainly never be as good in treating it as we would be if we were able to prevent it. That goes for all types of stroke and certainly for amyloid angiopathy-related stroke where the hope is to identify treatments that will lower the risk for amyloid-related rupture and hemorrhaging.

　　Greenberg 教授: 脑出血研究领域现状是还未建立急性干预明确预后的治疗方法。我们知道全面加强护理可改善卒中预后，有相当好的研究表明，出血性卒中后，住神经ICU病房比普通病房的患者预后更好，我们还不知道ICU的哪项服务使患者预后更好，或仅仅许多小的好处集中作用形成了我们观察到的明显好的预后。脑血管变性导致的卒中面临的现状和普通出血性卒中相同。现在还没有任何一种急性治疗方法被证实会对某种出血性卒中有效，例如，血管淀粉样病变与高血压性出血对比。我们正等待几大临床试验结果，尤其INTERACTⅡ（Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage）研究。遗憾的是，此结果不会在ISC公布。试验结果尚未公之于众，包括更严格的血压控制和颅内出血。STICHⅡ（Surgical Trial in Lobar Intracerebral Haemorrhage）研究侧重于出血早期尤其大脑表层手术治疗。我认为非常重要、也让许多组织困惑的是对预期会发生血管淀粉样变性出血的患者行手术移除血管是否安全。仍有人担心如果切断淀粉样变性的血管将会大出血，因为这种血管非常脆弱。在日常临床实践中，这种担忧好像有点多余。在STICHⅠ研究中，其中因血管淀粉样变性导致表面出血的亚组患者似乎受益，这一结果是STICHⅡ致力于血管淀粉样变性出血研究的内在动力。事实是至少STICHⅠ研究中出现了有希望的结果，这对于我来说就是非常好的证据，尽管我们不知道何种手术好或不好，但对于血管淀粉样变性的患者，手术至少是安全的。另一点我要补充的是，对于出血性卒中或普通卒中患者，尽管我们想改善卒中急性期治疗，但我们还是希望能做到预防卒中发生。即使我们能做到预防卒中发生，也肯定不会像治疗急性卒中一样好。这适用于所有卒中，当然也适用于血管淀粉样变性相关卒中。我们希望找到能降低淀粉样变性相关血管破裂和大出血风险的治疗方法。
 

　　<International Circulation>：Thank you very much. And one last question. Just out of my own curiosity. Why does cerebral amyloid angiopathy cause lobar hemorrhages as opposed to other kinds of hemorrhages?

　　《国际循环网》：非常感谢您，我还有最后一个小问题。只是出于我自己的好奇心。为什么脑血管淀粉样变性会导致脑叶出血，而不是其它种类的出血呢？

　Prof.Greenberg: There’s an easy answer and then there’s a hard answer. The easy answer is that it causes lobar hemorrhages because that’s where the amyloid is so there’s much more amyloid in those superficial vessels than the deep-penetrating vessels. So that part is no surprise. The next question is the much tougher one: “So why are those superficial vessels the ones where all the amyloid is?” There’s a theory with an amount of scientific support that there’s a drainage system of the amyloid from the center of the brain towards the outside parts of the brain and that the amyloid drains according to this pathway. Therefore the largest concentrations of it are in the outer parts of the brain because that is the destination point of the amyloid so that’s the vessels that get the majority of the burden. Well， anyways we do not have an exactly proven answer to that questions but that’s where the vessels gets the biggest majority of the burden.

　　Greenberg 教授: 这个问题可以简单回答也可以复杂回答。简单的回答就是，这种出血是由发生淀粉样变性的血管部位决定，因为表面血管发生血管淀粉样变性的概率大于深部血管。因此，发生这种情况不足为奇。下面一个问题就比较复杂，为什么表面血管容易发生淀粉样变性？一个有充分科学依据的理论认为，从大脑深部向外部有淀粉样物质排泄系统。淀粉样物质从这个系统排出。因此淀粉样物质浓度最大的部分在大脑外部，是淀粉样物质的终点，因此，大脑外部的血管更容易发生淀粉样变性。但无论如何，对这个问题还没有准确答案，大脑外部血管确实承受最大部分负担。

<International Circulation>：Well， that’s it for my questions. Thank you very much!

　　《国际循环网》：好了，我的问题问完了，非常感谢您的配合！