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• Letter to the Editor regarding "Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants"
  Birsen Ince, Gulcin Senel
  Published on: 5 May 2021

• Published on: 5 May 2021

  Letter to the Editor regarding "Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants"

  • Birsen Ince, Neurologist Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Neurology, Istanbul, Turkey
  • Other Contributors:
    • Gulcin Senel, Neurologist

  Dear Editor,
  We have read with interest a recent paper by Seiffge and his colleagues published in your journal (1). In their study entitled as “Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants”, the authors have investigated the role of small vessel disease on intracerebral hemorrhages (ICH) associated with the use of oral anticoagulation therapy. The authors showed that the small vessel disease with medium-to-high severity, detected by either computed tomography (CT) or magnetic resonance imaging (MRI), was significantly more prevalent in patients with ICH taking oral anticoagulants in compared to those without prior anticoagulation therapy (56.1% vs 43.5% on CT, and 78.7% vs 64.5% on MRI, respectively; p<0.001). Leukoaraiosis and atrophy were also reported to be more frequent and severe in patients with ICH related to anticoagulation therapy. We think that the results of the study are considerable emphasizing the importance of small vessel disease for ICH, which should therefore be implemented among the criteria of the risk stratification scores of bleeding.

  The use of the scoring systems for the risk stratification of the intracranial bleeding is practically important in patients who are the candidates for the anticoagulation therapy. A recent study investigating the risk factors predicting ICH in patients with atrial fibrillation under anticoagulation therapy demonstrated that the presence of white matter...

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  Dear Editor,
  We have read with interest a recent paper by Seiffge and his colleagues published in your journal (1). In their study entitled as “Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants”, the authors have investigated the role of small vessel disease on intracerebral hemorrhages (ICH) associated with the use of oral anticoagulation therapy. The authors showed that the small vessel disease with medium-to-high severity, detected by either computed tomography (CT) or magnetic resonance imaging (MRI), was significantly more prevalent in patients with ICH taking oral anticoagulants in compared to those without prior anticoagulation therapy (56.1% vs 43.5% on CT, and 78.7% vs 64.5% on MRI, respectively; p<0.001). Leukoaraiosis and atrophy were also reported to be more frequent and severe in patients with ICH related to anticoagulation therapy. We think that the results of the study are considerable emphasizing the importance of small vessel disease for ICH, which should therefore be implemented among the criteria of the risk stratification scores of bleeding.

  The use of the scoring systems for the risk stratification of the intracranial bleeding is practically important in patients who are the candidates for the anticoagulation therapy. A recent study investigating the risk factors predicting ICH in patients with atrial fibrillation under anticoagulation therapy demonstrated that the presence of white matter changes was one of the risk factors being significantly higher in patients having ICH than controls (66.6% versus 32.5% respectively, p=0.0001) (2). On the other hand, the authors concluded that although the presence of white matter changes was one of the risk factors predicting ICH in patients with atrial fibrillation under anticoagulation therapy, it failed to show a significant association with CHA2DS2-VASc or HAS-BLED scores. While the use of validated scoring systems was encouraged in prediction of the ‘risk’ versus ‘benefit’ reasoning when deciding whether or not to start/resume oral anticoagulation therapy in patients with atrial fibrillation, this discrepancy tells us that these scoring systems may benefit from some revisions. Indeed, we have previously discussed the need for the revisions in HAS-BLED, and suggested the incorporation of the presence of white matter abnormalities and leukoaraiosis into the scoring system, in addition with the type of stroke (whether ischemic or hemorrhagic of type), and the localization of previous hemorrhages (whether deep versus lobar in location) (3,4). The latest guideline of the European Society of Cardiology (ESC) for the diagnosis and the management of atrial fibrillation have also emphasized that there is a prominent increase in the occurrence of ICH in parallel with the increase in the numbers of cerebral micro bleeds (5). On the other hand, the effects of cerebral micro bleeds on the treatment strategies were reported to be proven.

  In the light of these data, it seems that some revisions are being required for the scoring systems, as supported by the recent study by Seiffge and his colleagues (1), demonstrating the importance of small vessel disease in patients with anticoagulation-associated ICH. The failure to demonstrate a significant association with the risk factors of ICH, including small vessel disease, and the CHA2DS2-VASc or HAS-BLED scores in the study by Paciaroni and his colleagues (2) may be explained, at least to some extent, by the shortcomings of the scoring systems to cover important risk factors of ICH in this group of patients, mainly the white matter abnormalities, leukoaraiosis, the type and the localization of previous strokes and the micro bleeds. In this era, the neuroimaging techniques are easily reachable in the detection of white matter abnormalities or cerebral micro bleeds, and the use of these data should be encouraged before a decision was made for the anticoagulation therapy. On these bases, we would like to emphasize the importance and the need for the revision in scoring systems to better cover the risk factors of ICH, which, we believe, will more adequately aid the (re)institution of the oral anticoagulation treatment.
  References
  1. Seiffge DJ, Wilson D, Ambler G, Banerjee G, Hostettler IC, Houlden H, et al. Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants. J Neurol Neurosurg Psychiatry. 2021; jnnp-2020-325299.
  2. Paciaroni M, Agnelli G, Giustozzi M, Caso V, Toso E, Angelini F, et al. Risk Factors for Intracerebral Hemorrhage in Patients With Atrial Fibrillation on Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention. Stroke. 2021;52(4):1450-1454.
  3. Ince B, Benbir G, Gozubatik-Celik G. Should HAS-BLED scoring be revised for better risk estimation in patients with intracerebral hemorrhage? Expert Rev Cardiovasc Ther. 2014;12(8):929-931.
  4. Ince B, Senel G. Deep versus lobar intracerebral hemorrhage on HAS-BLED scoring system. Chest. 2016;149(6):1589-1590.
  5. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart J. 2021;42(5):373–498.

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  Conflict of Interest:
  None declared.

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