Antithrombotic Drug Use, Cerebral Microbleeds, and Intracerebral Hemorrhage

Lovelock, Caroline; Cordonnier, Charlotte; Naka, Hiroyuki; Salman, Rustam Al-Shahi; Sudlow, Cathie; Sorimachi, Takatoshi; Werring, David J.; Grégoire, Stéphanie; Imaizumi, Toshio; Lee, Seung‐Hoon; Briley, Dennis; Rothwell, Peter M.

doi:10.1161/strokeaha.109.572594

Cited by 254 publications

(162 citation statements)

References 31 publications

(51 reference statements)

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“…The population‐based Rotterdam Scan study found that antiplatelet agent was related to the presence of CMBs, but anticoagulation was not (Darweesh et al., 2013; Vernooij et al., 2009). A systematic review including ICH and ischemic stroke/TIA found that both antiplatelet and warfarin were associated with presence of CMBs (Lovelock et al., 2010). In contrast, a study with asymptomatic elderly subjects showed no significant association of antithrombotic therapy with CMBs (Kim, Kwon, & Kwon, 2012).…”

Section: Discussionmentioning

confidence: 99%

Background and distribution of lobar microbleeds in cognitive dysfunction

et al. 2017

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ObjectivesCerebral microbleeds (CMBs) are often observed in memory clinic patients. It has been generally accepted that deep CMBs (D‐CMBs) result from hypertensive vasculopathy (HV), whereas strictly lobar CMBs (SL‐CMBs) result from cerebral amyloid angiopathy (CAA) which frequently coexists with Alzheimer's disease (AD). Mixed CMBs (M‐CMBs) have been partially attributed to HV and also partially attributed to CAA. The aim of this study was to elucidate the differences between SL‐CMBs and M‐CMBs in terms of clinical features and regional distribution.MaterialsWe examined 176 sequential patients in our memory clinic for clinical features and CMB location using susceptibility‐weighted images obtained on a 3T‐MRI. The number of lobar CMBs in SL‐CMBs and M‐CMBs was counted in each cerebral lobe and their regional density was adjusted according to the volume of each lobe.ResultsOf the total 176 patients, 111 patients (63.1%) had CMBs. Within the patients who had CMBs, M‐CMBs were found in 54 patients (48.6%), followed by SL‐CMBs in 35 (31.5%) and D‐CMBs in 19 (17.1%). The SL‐CMB group showed a significantly higher prevalence of family history of dementia, whereas the M‐CMB group showed an increasing trend toward hypertension and smoking. The prevalence of AD was significantly higher in the SL‐CMBs group, whereas the prevalence of AD with cerebrovascular disease was higher in the M‐CMBs group. The regional density of lobar CMBs was significantly higher in the occipital lobe in the M‐CMB group, whereas the SL‐CMB group showed higher regional density between regions an increasing tendency in the parietal and occipital lobe.ConclusionThe between‐group differences in clinical features and regional distribution indicate there to be an etiological relationship of SL‐CMBs to AD and CAA, and M‐CMBs to both HV and CAA.

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Section: Discussionmentioning

confidence: 99%

Background and distribution of lobar microbleeds in cognitive dysfunction

et al. 2017

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“…However, in the literature reviewed in this article, ischemic stroke occurred frequently in patients with giant aneurysms, and this must be considered during the period of postoperative medication. In addition, as the intracranial hemorrhage rate is known to be high in patients showing microbleeds on MRI, 19,20) MRI should be performed preoperatively, and the findings should be taken into consideration in evaluating the indications. Flow diverters have been used in many patients with large/giant cerebral aneurysms primarily in Western countries and have also been introduced to Japan with high expectations.…”

Section: Meta-analysismentioning

confidence: 99%

Clinical Evidence of Flow Diverters

Yoshimura

2017

JNET

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Clinical evidence regarding a new endovascular treatment device, flow diverter (FD), for large/giant cerebral aneurysms is introduced. Currently, three kinds of FD, Pipeline, Surpass, and FRED, are being used in our country.Pipeline: Pipeline was successfully placed in 107/108 patients (99.1%) in PUFS trial. An international study, IntrePED, collected clinical data of 793 patients with 906 aneurysms, and showed favorable clinical results with relatively low neurologic morbidity-mortality (7.4%). However, adverse events were more frequent in large, ruptured, and posterior circulation aneurysms. Ischemic stroke was the majority of complications (4.7%). On the other hand, delayed rupture of the treated aneurysm was rare (0.6%). Surpass:In a prospective, single-armed, multicenter clinical study of Surpass flow diverter, successful placement was observed in 161 of 186 aneurysms (98%), and neurologic death or any stroke within 6 months was seen in 18 patients (12%). FRED:In FRED, clinical reports regarding 29 patients with 34 aneurysms showed 100% successful placement and no complications in 26 cases (89%).A recent meta-analysis reported that FDs were used for unruptured aneurysms, particularly, of the internal carotid or vertebrobasilar artery, and fusiform, dissecting, or wide-necked saccular aneurysms, and progressive occlusion of the aneurysm during follow-up after the procedure and neurologic morbidity in 3.5% and death in 3.4% in 1483 patients with 1704 aneurysms.In conclusion, FDs are shown as relatively safe and useful devices for aneurysms with complex anatomical structures which are not treatable by coiling or clipping. A better clinical result is expected by selecting appropriate patients and careful treatment with FDs in the future.Keywords▶ cerebral aneurysm, review, evidence, flow diverter While the rupture rate is high in large/giant cerebral aneurysms, 1,2) they are often poor indications of usual clipping. Therefore, they have been treated by a combination of occlusion of the parent vessel and bypass surgery or stent-assisted coil embolization. However, surgical treatment is often highly invasive, 3,4) and endovascular treatment has been associated with a high postoperative recurrence rate 5-7) and the risk of exacerbating nerve compression symptoms, 8) because coils are placed in aneurysms. To solve these problems, the flow diverter, a self-expandable stent for the treatment of aneurysms, was developed. 9,10) This device is a stent made of fine mesh to be placed in the parent artery aimed to prevent enlargement or rupture of the aneurysm without inserting a coil into the aneurysm by diverting the flow and preventing blood from flowing into the aneurysm while preserving the parent vessel.This article summarizes and reviews the literature related to flow diverters. PipelinePipeline (Medtronic Neurovascular, Irvine, CA, USA) is the first flow diverter that has been developed and clinically applied. It is cylindrical mesh woven with wires of platinum/ tungsten and cobalt/chromium/nickel/molybdenum alloys.

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“…There is a potential for severe bleeding (including IPH) with therapeutic anticoagulation, even with the international normalized ratio (INR) in the goal range. An increased risk for microbleeds is seen with warfarin, and may presage an increased risk for symptomatic IPH (19). As the intensity of anticoagulation increases, so does the risk for IPH (18,20).…”

Section: Intracranial Hemorrhage During Medical Treatmentmentioning

confidence: 99%

Intracranial Hemorrhage

Naidech

2011

Am J Respir Crit Care Med

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Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuromonitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.

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Antithrombotic Drug Use, Cerebral Microbleeds, and Intracerebral Hemorrhage

Abstract: Background and Purpose-Cerebral microbleeds (MB) are potential risk factors for intracerebral hemorrhage (ICH), but it is unclear if they are a contraindication to using antithrombotic drugs.

Cited by 254 publications

References 31 publications

Background and distribution of lobar microbleeds in cognitive dysfunction

Background and distribution of lobar microbleeds in cognitive dysfunction

Clinical Evidence of Flow Diverters

Intracranial Hemorrhage

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