Number of Cerebral Microbleeds and Risk of Intracerebral Hemorrhage After Intravenous Thrombolysis

Abstract

Background and Purpose-Cerebral microbleeds (CMBs) are found in a substantial proportion of patients with ischemic stroke eligible for treatment with intravenous thrombolysis. Until now, there is limited data on the impact of multiple CMBs on occurrence of intracerebral hemorrhage (ICH) after intravenous thrombolysis. Methods-Between 2008 and 2013, all patients receiving MRI-based intravenous thrombolysis were identified within our prospective thrombolysis register. Number of CMBs was rated on pretreatment T2*-weighted MRI by a rater blinded to clinical data and follow-up. Outcomes of interest were occurrence of symptomatic ICH (sICH) and parenchymal hemorrhage (PH). Results-Among 326 included patients, 52 patients had a single CMB (16.0%), 19 had 2 to 4 CMBs (5.8%), and 10 had ≥5 CMBs (3.1%). Frequency of sICH/PH was 1.2%/5.7% in patients without CMBs, 3.8%/3.8% in patients with a single CMB, 10.5%/21.1% in patients with 2 to 4 CMBs, and 30.0%/30.0% in patients with ≥5 CMBs, respectively (each P for trend <0.01). The unadjusted odds ratio per additional CMB for sICH was 1.19 (95% confidence interval, 1.07-1.33; P<0.01) and for PH was 1.13 (95% confidence interval, 1.03-1.24; P=0.01). Compared with patients without CMBs, both patients with 2 to 4 CMBs (P=0.02/P=0.02) and patients with ≥5 CMBs (P<0.01/P<0.01) had significantly increased odds ratios for sICH and PH, whereas in patients with a single CMB, odds ratios were not significantly increased (P=0.21/P=0.59). The association of CMB burden with sICH/PH remained significant after adjustment for possible confounders (age, age-related white matter changes score, atrial fibrillation, onset-to-treatment time, prior statin use, and systolic blood pressure on admission). Conclusions-Our findings indicate a higher risk of sICH and PH after intravenous thrombolysis when multiple CMBs are present, with a graded relationship to increasing baseline CMB number. (Stroke. 2014;45:2900-2905.)

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

“…Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2-4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3-to 6-month functional outcome (modified Rankin score >2). We performed a large-scale pooled individual patient data meta-analysis of quality observational studies to test the following hypotheses: (1) there is a relationship between increasing CMB burden and ICH risk 8,9 ; (2) strictly lobar CMBs (reflecting possible or probable cerebral amyloid angiopathy [CAA]) and mixed or strictly deep CMBs (likely associated with hypertensive arteriopathy) have different effects on ICH risk; (3) CMBs are associated more strongly with the risk of remote ICH than other ICH types 10 ; and (4) CMBs are associated with worse functional outcome. …”

Cerebral Amyloid Angiopathy or Frontotemporal Dementia? A Case Study

“…SCAA appears to be an important differential diagnosis in patients with progressive neuropsychiatric symptoms and executive impairment [17,18,41]. The diagnosis of SCAA is crucial and can have essential therapeutic consequences with regard to thrombolytic or anticoagulation therapy [42,43] blood pressure control [44] and prognosis due to their risk of further spontaneous brain hemorrhages and consequent dementia [45]. MRI depicting vascular lesions currently represents the best disease marker of SCAA [46].…”

Multimodal Diagnostic Imaging for Hyperacute Stroke

“…[14][15][16] One study showed a higher risk of symptomatic hemorrhage after intravenous thrombolysis in patients with Ͼ5 microbleeds but no association with less favorable outcome. 17 More studies to assess the safety and effectiveness of thrombolysis in patients with microbleeds are needed.…”