Aspirin Treatment Increases the Risk of Cerebral Microbleeds

Abstract

Antiplatelet agents, especially aspirin, are effective for the prevention of secondary stroke and cardiovascular diseases, and have been widely used in most patients in China. Long-term antiplatelet therapy reduces the risk of recurrent stroke, myocardial infarction, and vascular death in patients with stroke or ischemic heart disease, but it may be associated with increased risk of intracerebral hemorrhage (ICH), [1][2][3][4] which is an uncommon but often fatal or disabling treatment complication. Identification of risk factors will therefore help to prevent ICH in patients receiving aspirin, especially in long-term users.Cerebral microbleeds (CMBs) are considered to be indicative of bleeding-prone microangiopathy and ICH. They appear as round hypointense regions on T2*-weighted magnetic resonance ABSTRACT: Background: The objective of the study was to determine the frequency of cerebral microbleeds (CMBs) by using phasesensitive imaging in patients with previous transient ischemic attack (TIA) or stroke who were receiving aspirin treatment. Methods: We retrospectively analyzed 300 outpatients with ischemic cerebrovascular disease: 150 had been receiving aspirin treatment for >1 year (patients), and 150 controls had not previously received aspirin. Cerebral microbleeds were defined by a trained observer (blinded to clinical details) according to results of T2-weighted, T1-weighted, diffusion-weighted, and phase-sensitive magnetic resonance imaging (MRI). Numerous vascular risk factors including white matter hyperintensity (WMH), duration of aspirin treatment, age, hypertension or diabetes mellitus were investigated for a possible association with the presence of CMBs in the two groups. Results: The frequency of CMBs (60/150 (40% ) vs 18/150 (12%); odds ratio 4.899, p <0.0001) and intracerebral hemorrhage (ICH)(42/150 (28% ) vs 2/150 (1%); odds ratio 28.778, p <0.0001) were significantly higher in the patients than in the controls. Among patients, those using aspirin for >5 years(42/68 (62%) showed a higher frequency of CMBs than those receiving aspirin for ≤ 5 years(18/82 (22%); odds ratio 5.744, p<0.0001). WMH (p=0.020/0.030, 0.007/0.000) age (p=0.007/0.000) and hypertension (p=0.000/0.033), in patients and controls respectively, were each associated with CMBs. Conclusions: There was a clear impact of aspirin treatment on CMBs associated with intracerebral hemorrhage in Chinese patients. The frequency of CMBs and hemorrhagic complications was higher in patients treated with long-term aspirin.RÉSUMÉ: Le traitement par l'aspirine augmente le risque de micro saignements cérébraux. Contexte : L'objectif de l'étude était de déterminer la fréquence de micro saignements cérébraux (MSC) au moyen de l'imagerie par contraste de phase chez les patients qui recevaient de l'aspirine suite à des accès ischémiques transitoires cérébraux (ITC) ou à un accident vasculaire cérébral. Méthode : Nous avons analysé rétrospectivement les dossiers de 300 patients externes atteints d'une maladie cérébrovasculaire ischémique : 150 re...

Cerebral amyloid angiopathy–associated intracerebral hemorrhage: pathology and management

“…Gorelick 25 demonstrated that cerebral microhemorrhages were more prevalent among patients taking antiplatelet medications (adjusted OR 1.71 [95% CI 1.21-2.41]), and these microhemorrhages were more likely to be in lobar locations among aspirin users than in nonusers (adjusted OR compared with nonusers 2.70 [95% CI 1.45-5.04]). In a similar study by Ge and colleagues, 22 patients using aspirin for longer than 5 years had a higher frequency of microhemorrhage than those taking aspirin for less than 5 years (p < 0.0001).…”

Cerebral Microbleeds

“…20,21 In patients with ischemic stroke, both a French and a Chinese study showed the association between antithrombotic use as a whole or aspirin use and the presence of CMBs. 22,23 A Japanese study found that antiplatelet use was associated with the presence of CMBs in 412 patients with ICH (OR, 2.418; CI, 1.236-4.730) but not in 1502 patients with ischemic stroke. 24 In patients with ICH, aspirin (OR, 2.160; CI, 1.050-4.443), but not clopidogrel, cilostazol, or ticlopidine, was associated with CMBs, especially deep CMBs.…”

No significant association of aspirin use with cerebral microbleeds in the asymptomatic elderly

“…In previous studies, aspirin use was associated with the presence of CMBs, but the target population is different from our study [7,8]. In the Rotterdam Scan Study, subjects were enrolled from a communitybased population, and 3.4% had a history of cerebrovascular disease [7].…”

“…In the Rotterdam Scan Study, subjects were enrolled from a communitybased population, and 3.4% had a history of cerebrovascular disease [7]. In the Chinese study, all patients included in the analysis had a history of ischemic cerebrovascular disease [8]. They used a statistical method to exclude the confounding effect of cerebrovascular disease, but the bias from cerebrovascular disease might not have disappeared completely, because CMBs may be associated with the presence of cerebrovascular disease, and aspirin may be more often prescribed to persons with an increased risk of developing CMBs.…”

“…To predict the risk of ICH after aspirin use is not simple, but in certain situations such as cerebral amyloid angiopathy, the incidence of ICH is known to increase [5]. Recently, there have been some reports that the use of aspirin is associated with CMBs, which is a presumed marker of future ICH, in subjects with cerebrovascular diseases [6][7][8]. However, this association between aspirin use and CMBs is not confirmed in the general population and is still controversial [9,10], and there are many people who use aspirin because of vascular problems other than ischemic stroke.…”