Validation of the Boston Criteria Version 2.0 for Cerebral Amyloid Angiopathy in Patients Presenting with Intracerebral Hemorrhage Who Underwent Surgical Evacuation and Brain Biopsy

Introduction: Cerebral amyloid angiopathy (CAA) is a major cause of lobar intracranial hemorrhage (ICH) often associated with worse surgical outcomes and higher rebleeding rates. The updated Boston criteria 2.0 was released in 2022 as a new criteria to evaluate the likelihood of CAA etiology. The objective of this study was to validate the Boston criteria 2.0 as a predictor of CAA and compare it to the prior version, the modified Boston criteria 1.5.

Methods: From 2015 to 2021, biopsies were collected for patients undergoing minimally invasive ICH evacuation and analyzed by the pathology department to assess for CAA. Additionally, magnetic resonance scans were performed in the acute period and evaluated using the Boston criteria 2.0 for both possible and probable CAA based on MRI biomarkers including additional lobar hemorrhagic lesions (ie, microbleeds or cortical siderosis) or one white matter characteristic (ie, severe visible perivascular spaces in the centrum semiovale or multispot white matter hyperintensities) with the absence of deep hemorrhagic lesions. The diagnostic accuracy of the v2.0 criteria was compared to the v1.5 criteria.

Results: Of 231 patients undergoing ICH evacuation, 166 patients met the study inclusion criteria. For the Boston criteria 2.0, the sensitivities and specificities, respectively, were 68.9% and 93.4% for probable CAA, and 73.3% and 86.8% for possible CAA. In comparison, for the modified Boston criteria 1.5, the sensitivities and specificities, respectively, were 26.7% and 96.7% for probable CAA, and 88.9% and 76.0% for possible CAA. Both the positive and negative predictive values for probable CAA were improved in the v2.0 criteria (79.5% and 90.0%) compared to the v1.5 criteria (75.0% and 78.0%).

Conclusion : The inclusion of additional biomarkers for CAA neuropathology in the v2.0 Boston criteria greatly enhances its sensitivity for probable CAA without compromising specificity, thereby improving its diagnostic accuracy for ICH etiology in patients undergoing spontaneous ICH evacuation.