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Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds

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Abstract

Background

Retrospective studies suggested that cerebral microbleeds (MB) on magnetic resonance images (MRI) increase risk of intracerebral haemorrhage (ICH).

Objective

To compare the benefit of anti-thrombotic agents in stroke prevention (absolute risk reduction 2.49 –6 %) versus risk of ICH in ischaemic stroke patients with MB.

Materials and methods

We prospectively studied patients admitted consecutively for acute ischaemic stroke between 1999 and 2004. MB on MRI were documented. Primary end points were subsequent ICH, recurrent cerebral infarct (CI) and mortality.

Results

A total of 908 patients were recruited. MB were identified in 252 (27.8 %) patients. Mean follow-up period was 26.6 ± 15.4 months. Risk of subsequent ICH increased significantly with quantity of MB: 0.6 % (no MB), 1.9 % (1 MB), 4.6 % (2–4 MB) and 7.6 % (≥ 5 MB) (p < 0.001). There was also a significant increase in mortality from ICH: 0.6 %, 0.9 %, 1.5 % and 3.8 % respectively (p = 0.054). Rate of recurrent CI was 9.6 %, 5.6 %, 21.5 % and 15.2 % respectively (p = 0.226). Mortality from CI and myocardial infarction did not increased with quantity of MB. Survival analyses showed that age, presence of MB, mixed cortical-subcortical distribution of MB were independent predictors of subsequent ICH.

Conclusion

Risk and mortality of ICH increased with quantity of MB. As tendency to recurrent CI exceed that of ICH, anti-thrombotic agents are still warranted. However, in patients with ≥ 5 MB, the high risk and mortality of ICH seem to outweigh the modest benefit of antithrombotic agents. Extra precautions should be taken to minimize risk of ICH. Further studies in patients on Coumadin and assessment of functional outcome are warranted to support these preliminary findings.

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References

  1. Greenberg SM, Eng JA, Ning M, Smith EE, Rosand J (2004) Hemorrhage burden predicts recurrent intracerebral hemorrhage after lobar hemorrhage. Stroke 35(6):1415–1420

    Article  PubMed  Google Scholar 

  2. Kinoshita T, Okudera T, Tamura H, Ogawa T, Hatazawa J (2000) Assessment of Lacunar Hemorrhage Associated With Hypertensive Stroke by Echo-Planar Gradient-Echo T2*-Weighted MRI. Stroke 31(7):1646–1650

    CAS  PubMed  Google Scholar 

  3. Tanaka A, Ueno Y, Nakayama Y, Takano K, Takebayashi S (1999) Small Chronic Hemorrhages and Ischemic Lesions in Association With Spontaneous Intracerebral Hematomas. Stroke 30(8):1637–1642

    CAS  PubMed  Google Scholar 

  4. Fazekas F, Kleinert R, Roob G, Kleinert G, Kapeller P, Schmidt R, Hartung HP (1999) Histopathologic Analysis of Foci of Signal Loss on Gradient-Echo T2*-Weighted MR Images in Patients With Spontaneous Intracerebral Hemorrhage: Evidence of Microangiopathy-Related Microbleeds. AJNR Am J Neuroradiol 20(4):637–642

    CAS  PubMed  Google Scholar 

  5. Wong KS, Chan YL, Liu JY, Gao S, Lam WW (2003) Asymptomatic Microbleeds As a Risk Factor for Aspirin-Associated Intracerebral Hemorrhages. Neurology 60(3):511–513

    CAS  PubMed  Google Scholar 

  6. Fan YH, Zhang L, Lam WW, Mok VC, Wong KS (2003) Cerebral Microbleeds As a Risk Factor for Subsequent Intracerebral Hemorrhages Among Patients With Acute Ischemic Stroke. Stroke 34(10):2459–2462

    Article  PubMed  Google Scholar 

  7. Greenberg SM, Finklestein SP, Schaefer PW (1996) Petechial Hemorrhages Accompanying Lobar Hemorrhage: Detection by Gradient-Echo MRI. Neurology 46(6):1751–1754

    CAS  PubMed  Google Scholar 

  8. Greenberg SM, O’Donnell HC, Schaefer PW, Kraft E (1999) MRI Detection of New Hemorrhages: Potential Marker of Progression in Cerebral Amyloid Angiopathy. Neurology 53(5):1135–1138

    CAS  PubMed  Google Scholar 

  9. Lee SH, Bae HJ, Ko SB, Kim H, Yoon BW, Roh JK (2004) Comparative Analysis of the Spatial Distribution and Severity of Cerebral Microbleeds and Old Lacunes. J Neurol Neurosurg Psychiatry 75(3):423–427

    Article  PubMed  Google Scholar 

  10. Tajitsu K, Yokoyama S, Taguchi Y, Kusumoto K (2006) The Correlation Between Lacunes and Microbleeds on Magnetic Resonance Imaging in Consecutive 180 Patients. No Shinkei Geka 34(5):483–489

    PubMed  Google Scholar 

  11. Wardlaw JM, Lewis SC, Keir SL, Dennis MS, Shenkin S (2006) Cerebral Microbleeds Are Associated With Lacunar Stroke Defined Clinically and Radiologically, Independently of White Matter Lesions. Stroke 37(10):2633–2636

    Article  PubMed  Google Scholar 

  12. Fiehler J, Albers GW, Boulanger JM, Derex L, Gass A, Hjort N, Kim JS, Liebeskind DS, Neumann-Haefelin T, Pedraza S, Rother J, Rothwell P, Rovira A, Schellinger PD, Trenkler J (2007) Bleeding Risk Analysis in Stroke Imaging Before ThromboLysis (BRASIL): Pooled Analysis of T2*-Weighted Magnetic Resonance Imaging Data From 570 Patients. Stroke 38(10):2738–2744

    Article  PubMed  Google Scholar 

  13. Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients (2002) BMJ 324(7329):71–86

  14. Saxena R, Koudstaal P (2004) Anticoagulants Versus Antiplatelet Therapy for Preventing Stroke in Patients With Nonrheumatic Atrial Fibrillation and a History of Stroke or Transient Ischemic Attack. Cochrane Database Syst Rev (4):CD000187

  15. Wahlund LO, Barkhof F, Fazekas F, Bronge L, Augustin M, Sjogren M, Wallin A, Ader H, Leys D, Pantoni L, Pasquier F, Erkinjuntti T, Scheltens P (2001) A New Rating Scale for Age-Related White Matter Changes Applicable to MRI and CT. Stroke 32(6):1318–1322

    CAS  PubMed  Google Scholar 

  16. Saloheimo P, Ahonen M, Juvela S, Pyhtinen J, Savolainen ER, Hillbom M (2006) Regular Aspirin-Use Preceding the Onset of Primary Intracerebral Hemorrhage Is an Independent Predictor for Death. Stroke 37(1):129–133

    Article  CAS  PubMed  Google Scholar 

  17. Kidwell CS, Saver JL, Villablanca JP, Duckwiler G, Fredieu A, Gough K, Leary MC, Starkman S, Gobin YP, Jahan R, Vespa P, Liebeskind DS, Alger JR, Vinuela F (2002) Magnetic Resonance Imaging Detection of Microbleeds Before Thrombolysis: an Emerging Application. Stroke 33(1):95–98

    Article  PubMed  Google Scholar 

  18. Derex L, Nighoghossian N, Hermier M, Adeleine P, Philippeau F, Honnorat J, Yilmaz H, Dardel P, Froment JC, Trouillas P (2004) Thrombolysis for Ischemic Stroke in Patients With Old Microbleeds on Pretreatment MRI. Cerebrovasc Dis 17(2–3):238–241

    Article  CAS  PubMed  Google Scholar 

  19. Lee SH, Kwon SJ, Kim KS, Yoon BW, Roh JK (2004) Cerebral Microbleeds in Patients With Hypertensive Stroke. Topographical Distribution in the Supratentorial Area. J Neurol 251(10):1183–1189

    Article  PubMed  Google Scholar 

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Correspondence to Lawrence K. S. Wong MD.

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Soo, Y.O.Y., Yang, S.R., Lam, W.W.M. et al. Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds. J Neurol 255, 1679–1686 (2008). https://doi.org/10.1007/s00415-008-0967-7

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  • DOI: https://doi.org/10.1007/s00415-008-0967-7

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