Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Endovascular Thrombectomy

Abstract

Objective—To determine whether pre-treatment cerebral microbleeds (CMBs) presence and burden are correlated with an increased risk of intracranial hemorrhage (ICH) or poor functional outcome following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS).Methods—Consecutive patients treated by EVT for anterior circulation AIS were retrospectively analyzed. Experienced neuroradiologists blinded to functional outcomes rated CMBs on T2*-MRI using a validated scale. We investigated associations of CMB presence and burden with ICH and poor clinical outcome at 3 months (modified Rankin score >2).Results—Among 513 patients, 281 (54.8%) had a poor outcome and 89 (17.3%) had ≥1 CMBs. A total of 190 (37%) patients experienced ICH, in which 66 (12.9%) were symptomatic. CMB burden was associated with poor outcome in a univariable analysis (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.03–1.36 per 1-CMB increase; P=0.02), but significance was lost after adjustment for sex, age, stroke severity, hypertension, diabetes mellitus, atrial fibrillation, prior antithrombotic medication, intravenous thrombolysis, and reperfusion status (OR, 1.05; 95% CI, 0.92–1.20 per 1-CMB increase; P=0.50). Results remained nonsignificant when taking into account CMB location or presumed underlying pathogenesis. CMB presence, burden, location, nor presumed pathogenesis was independently correlated with ICH.Conclusions—Poor functional outcome or ICH were not correlated with CMB presence or burden on pre–EVT MRI after adjustment for confounding factors. Excluding such patients from reperfusion therapies is unwarranted.Classification of Evidence—This study provides Class II evidence that in patients with AIS undergoing EVT, after adjustment for confounding factors, the presence of CMBs is not significantly associated with clinical outcome or the risk of ICH.

Cerebral small vessel disease and intracranial bleeding risk: Prognostic and practical significance

“…In a retrospective cohort study of 513 patients treated with stent retriever or aspiration devices, CMB presence or burden on pretreatment MRI was associated neither with symptomatic ICH, nor reperfusion probability or functional outcome in adjusted analyses. 42 A smaller previous observational study reached similar conclusions. 43 Interestingly, a recent retrospective analysis of the German Stroke Registry suggests that patients meeting modified Boston criteria for CAA might also benefit from MT (OR for mRS 0–2 with successful reperfusion: 6.82, 95% CI = 1.77–26.3), with similar rates of post-MT ICH to patients without CAA.…”

Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients

“…The AtRial Cardiopathy and Antithrombotic Drugs In Prevention After Cryptogenic Stroke (ARCADIA) trial ( 8 ) and the Apixaban for Treatment of Embolic Stroke of Undetermined Source (ATTICUS) trial ( 39 , 40 ) are specifically randomizing patients with biomarker driven atrial cardiopathy (though different criteria than our study) to anticoagulation vs. antiplatelet therapy and may help answer some of these questions. Atrial cardiopathy may increase subclinical risk of embolic stroke, and with the addition of the findings of this study that risk may be marked by CMB ( 41 ). Future studies should investigate the role of anticoagulation for atrial cardiopathy and also consider whether there are differences in the number of CMB.…”

Effect of Cerebral Small Vessel Disease Burden on Outcomes in Patients With Acute Ischemic Stroke Receiving Endovascular Treatment

“…It’s noted that there was no significant difference in the safety outcomes when using either of the two scores. Previous studies also showed that the presence of CMBs was not significantly associated with the risk of ICH in patients receiving EVT ( Shi et al, 2016 ; Derraz et al, 2021 ). However, considering the small sample of the study, we should be cautious when interpreting the relationship between SVD burden and the safety outcome.…”

“…The association between SVD and the outcome in patients receiving EVT has also been investigated. Among these SVD markers, brain atrophy was reported to be associated with outcome and mortality after mechanical thrombectomy ( Diprose et al, 2019 ; Lauksio et al, 2021 ), whereas cerebral microbleeds not ( Shi et al, 2016 ; Derraz et al, 2021 ). The association between WMH and clinical outcomes has been reported with conflicting results ( Atchaneeyasakul et al, 2017 ; Boulouis et al, 2019 ).…”