Antithrombotic Therapy and Bleeding Risk in a Prospective Cohort Study of Patients With Cerebral Cavernous Malformations

Abstract

Background and Purpose-Cerebral cavernous malformations (CCMs) are one of the most frequently diagnosed vascular malformations of the brain and constitute a potential source of intracranial hemorrhage. In CCM patients suffering ischemic stroke or heart disease, the use of anticoagulants or antiplatelet therapy is generally avoided by fear of hemorrhagic complications, but no systematic studies exist to support this hypothesis. Methods-We prospectively followed-up consecutive patients with a diagnosis of one or more CCMs in a prospective database since 2008. Retrospective data collection was used for patients with a diagnostic event or imaging studies done before first assessment. Symptomatic hemorrhage and other focal neurological events during prospective follow-up were defined according to the current guidelines of the Angioma Alliance Scientific Advisory board. Results-A total of 87 patients were prospectively enrolled in our cohort [50 women (57%), mean age 44.8 years (SD ± 17.6), mean follow-up 3.9 years], harboring a total of 738 CCMs. Fifty-five patients (63%) had a single CCM, and 32 patients (37%) had multiple CCMs. Longitudinal follow-up included 16 (18%) patients receiving long-term antithrombotic therapy by antiplatelet treatment (n=11) or oral anticoagulants (n=5). During 5536 lesion-years of observation, none of the patients under antithrombotic therapy experienced CCM hemorrhage on follow-up. Conclusions-Our observational data suggest that long-term antithrombotic treatment by antiplatelet drugs or warfarin does not increase the frequency of CCM-related hemorrhage. Patients harboring single or multiple CCMs suffering ischemic stroke or heart disease should not be withheld antithrombotic therapy. (Stroke. 2012;43:3196-3199.)

The Role of Magnetic Resonance Imaging in Management of Patients With Nonlobar Hypertensive Intracerebral Hemorrhage

“…However, there is little evidence that long-term antiplatelet drug treatment increases the frequency of cavernoma-related ICH. 7,8 It is therefore conceivable to suggest that MRI findings led to an evidence-based management modification in only 1 (4%) of the 24 patients. Yet, even in that patient who had a history of high blood pressure, the possibility that his ICH was hypertensive and not secondary to CAA could not be ruled out.…”

Second European Stroke Science Workshop

“…Observed average annual bleeding rates are high in malformations with symptomatic hemorrhagic presentation (≈6% per year for either type) but seem low for untreated lesions that have been diagnosed unruptured (CCM, 0.5%; AVMs, 1% per year). 48,49 The recommended treatment for symptomatic CCMs is neurosurgical excision (estimated crude treatment-associated morbidity, 8%; mortality, 2%), whereas stereotactic radiotherapy remains highly controversial because of potentially higher complication rates. Interventional management of brain AVMs is at times complex and includes neurosurgery, endovascular embolization, and stereotactic radiotherapy, either alone or in any combination.…”

Acute Ischaemic Stroke Treated with Intravenous Thrombolysis in a Patient with a Known Large Brainstem Cavernous Malformation - Case Report and Literature Review

“…Our patient represented a month after initial TIA where his MRI scan had shown a large cavernous malformation in the brainstem, and our initial concern was that of acute intracerebral haemorrhage. He was discharged on single antiplatelet medication to be used long term [2]. Plain CT Brian imaging excluded this and with lack of evidence and concern of bleeding risk of such a lesion, our stroke team was very apprehensive even to discuss the option of thrombolysis.…”