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Advancing Diagnostic Criteria For Sporadic Cerebral Amyloid Angiopathy: Study Protocol For A Multicenter MRI-pathology Validation Of Boston Criteria V2.0

Andreas Charidimou, Matthew P Frosch, Rustam Al-Shahi Salman, Jean-Claude Baron, Charlotte Cordonnier, Mar Hernandez-Guillamon, Jennifer Linn, Nicolas Raposo, Mark Rodrigues, Jose Rafael Romero, Julie A Schneider, Stefanie Schreiber, Eric E Smith, Mark A van Buchem, Anand Viswanathan, Frank A Wollenweber, David J Werring, Steven M Greenberg,

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Rationale The Boston criteria are used worldwide for the in vivo diagnosis of cerebral amyloid angiopathy and are the basis for clinical decision-making and research in the field. Given substantial advances in cerebral amyloid angiopathy's clinical aspects and MRI biomarkers, we designed a multicenter study within the International cerebral amyloid angiopathy Association aimed at further validating the diagnostic accuracy of the Boston and potentially improving and updating them. Aim We aim to derive and validate an updated “version 2.0” of the Boston criteria across the spectrum of cerebral amyloid angiopathy-related presentations and MRI biomarkers. Sample size estimates Participating centers with suitable available data (see Methods) were identified from existing collaborations and an open invitation to the International Cerebral Amyloid Angiopathy Association emailing list. Our study sample will include: (1) a derivation cohort – Massachusetts General Hospital (MGH), Boston cases from inception to 2012 (∼150 patients); (2) temporal external validation cohort – MGH, Boston cases from 2012 to 2018 (∼100 patients); and (3) geographical external validation cohort – non-Boston cases (∼85 patients). Methods and design Multicenter collaborative study. We will collect and analyze data from patients' age ≥ 50 with any potential sporadic cerebral amyloid angiopathy-related clinical presentations (spontaneous intracerebral hemorrhage, transient focal neurological episodes and cognitive impairment), available brain MRI (“index test”), and histopathologic assessment for cerebral amyloid angiopathy (“reference standard” for diagnosis). Trained raters will assess MRI for all prespecified hemorrhagic and non-hemorrhagic small vessel disease markers of interest, according to validated criteria and a prespecified protocol, masked to clinical and histopathologic features. Brain tissue samples will be rated for cerebral amyloid angiopathy, defined as Vonsattel grade ≥2 for whole brain autopsies and ≥1 for cortical biopsies or hematoma evacuation. Based on our estimated available sample size, we will undertake pre-specified cohort splitting as above. We will: (a) pre-specify variables and statistical cut-offs; (b) examine univariable and multivariable associations; and (c) then assess classification measures (sensitivity, specificity etc.) for each MRI biomarker individually, in relation to the cerebral amyloid angiopathy diagnosis reference standard on neuropathology in a derivation cohort. The MRI biomarkers strongly associated with cerebral amyloid angiopathy diagnosis will be selected for inclusion in provisional (probable and possible cerebral amyloid angiopathy) Boston criteria v2.0 and validated using appropriate metrics and models. Study outcomes Boston criteria v2.0 for clinical cerebral amyloid angiopathy diagnosis. Discussion This work aims to potentially update and improve the diagnostic test accuracy of the Boston criteria for cerebral amyloid angiopathy and to provide wider validation of the criteria in a large sample. We envision that this work will meet the needs of clinicians and investigators and help accelerate progress towards better treatment of cerebral amyloid angiopathy.