Prevalence and Risk Factors of Silent Cerebral Microbleeds in Patients with Coronary Artery Disease

ObjectivesCerebral microbleeds (CMBs), which can be detected by gradient-echo T2*-weighted magnetic resonance imaging (MRI), represent small chronic brain hemorrhages caused by structural abnormalities in cerebral small vessels. CMBs are known to be a potential predictor of future stroke, and are associated with age, various cardiovascular risk factors, cognitive impairment, and the use of antithrombotic drugs. Patients with coronary artery disease (CAD) are at potentially high risk of CMBs due to the presence of coexistent conditions. However, little is known about CMBs in patients with CAD. We aimed to identify the factors associated with the presence of CMBs among patients with CAD.MethodsWe evaluated 356 consecutive patients [mean age, 72 ± 10 years; men = 276 (78%)] with angiographically proven CAD who underwent T2*-weighted brain MRI. The brain MRI was assessed by researchers blinded to the patients’ clinical details.ResultsCMBs were found in 128 (36%) patients. Among 356 patients, 119 (33%) had previously undergone percutaneous coronary intervention (PCI), and 26 (7%) coronary artery bypass grafting (CABG). There was no significant relationship between CMBs and sex, hypertension, dyslipidemia, diabetes mellitus, anticoagulation therapy, antiplatelet therapy, or prior PCI. CMBs were significantly associated with advanced age, previous CABG, eGFR, non-HDL cholesterol, carotid artery disease, long-term antiplatelet therapy, and long-term dual antiplatelet therapy (DAPT) using univariate logistic regression analysis. The multivariate logistic regression analysis showed that long-term antiplatelet therapy (odds ratio, 1.73; 95% CI, 1.06 – 2.84; P = 0.03) or long-term DAPT (odds ratio, 2.92; 95% CI, 1.39 – 6.17; P = 0.004) was significantly associated with CMBs after adjustment for confounding variables.ConclusionsCMBs were frequently observed in patients with CAD and were significantly associated with long-term antiplatelet therapy, especially long-term DAPT.     

The impact of cerebral microbleeds on intracerebral hemorrhage and poor functional outcome of acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis

It is still controversial whether pre-existing cerebral microbleeds (CMBs) increase the risks of intracranial hemorrhage (ICH) and poor functional outcome (PFO) in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT). Therefore, we performed a systematic review and meta-analysis to determine the impact of CMBs on ICH and PFO of AIS patients with IVT. We searched PubMed, EMBASE and Web of Science from inception to August 3, 2016, with language restriction in English. We included studies that reported the relationship between CMBs and ICH or PFO after thrombolysis. Two retrospective and nine prospective studies met inclusion criteria (total 2702 patients). The overall prevalence of CMBs on pre-IVT MRI scans was 24.0%. Pre-existing CMBs on MRI scans were not significantly associated with a higher risk of early sICH (OR 1.74; 95% CI 0.91–3.33; I ² = 44.5%). Subgroup analyses did not substantially influence these associations. The presence of CMBs was associated with the increased risk of 3-month PFO (OR 1.58; 95% CI 1.08–2.31; I ² = 54.2%), PH (OR 2.14; 95% CI 1.34–3.42; I ² = 11.0%) and any ICH (OR 1.42; 95% CI 1.04–1.95; I ² = 0.0%), respectively. This meta-analysis showed that CMBs presence was not significantly associated with the increased risk of early sICH after IVT. However, the results also demonstrated that CMBs presence increased the risks of 3-month PFO, PH and any ICH after IVT. Due to a small number of included studies and methodological limitations, the results of this meta-analysis should be interpreted cautiously. CMBs presence should not be a contraindication to IVT for AIS patients based on the existing evidence.     

Absence of Microbleeds Reduces the Risk for Recurrent Intracerebral Hemorrhage

Background: Many known risk factors, including hypertension and hyperlipidemia cause intracerebral hemorrhage (ICH). Recently, microbleeds have been identified as one of the factors leading to ICH. While some patients have been found to have recurrent ICH, risk factors for recurrent ICH are scarcely reported. We conducted an observational study on the risk-factors of recurrent ICH, comparing stroke patients with a single hemorrhagic episode and those with recurrent ICH. Methods: A retrospective analysis of a single-center database was performed to analyze the clinical presentation and characteristics of patients with a single and recurrent ICH. From January 2016 to December 2017, a total of 317 patients were analyzed based on suspected factors including patients’ sex, age, medical history, antiplatelet therapy use, and presence of microbleeds on images. Results: Of the 317 patients, 36 patients (11.4%) developed a second episode of cerebral hemorrhage. Brain magnetic resonance imaging (MRI) of the patients without microbleeds, predicted reduced risk of recurrence. This is the first report strongly associating the presence of microbleeds with the possibility of a recurrent ICH. Other factors under study did not show an apparent association with recurrent ICH probably because of the high statistical significance obtained with the presence of microbleeds. Conclusion: Our findings revealed that the absence of microbleeds on images is a factor that strongly predicts a reduced risk for recurrent ICH and that the detection of microbleeds on MRI performed in patients with a single hemorrhagic episode, is useful in defining further therapeutic management. These findings may benefit physicians treating stroke patients.     

R558C NOTCH3 Mutation in a CADASIL Patient with Intracerebral Hemorrhage: A Case Report with Literature Review

BackgroundCerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a monogenic cerebral small-vessel disease, which is characterized by migraine, recurrent ischemic strokes, psychiatric disorder, progressive cognitive decline, and occasionally intracerebral hemorrhage (ICH). ICH events have been reported in a high proportion of East Asian CADASIL patients with R544C mutation in exon 11 of NOTCH3; however, whether any other specific NOTCH3 mutation determines the ICH phenotype has yet to be explored.Case presentationWe report the case of a 60-year-old male CADASIL patient with a novel R558C mutation in exon 11 of the NOTCH3 gene, who presented with ICH in the basal ganglia and cerebellum. Brain imaging revealed multiple confluent white matter hyperintensities and abundant cerebral microbleeds (CMBs) in the bilateral basal ganglia, thalamus, and cerebellum. The patient had been having recurrent ischemic strokes prior to this ICH event, and had taken antiplatelet and antihypertensive agents for six months. We analyzed the possible reasons for ICH onset in the patient to recommend certain guidelines for the clinic.ConclusionsNovel R558C mutation-related CADASIL vasculopathy and numerous CMBs, uncontrolled hypertension, and antiplatelet therapy could collectively contribute to ICH onset in the patient with CADASIL. These findings suggest that a diagnosis of CADASIL should also be considered when patients present with ICH, whenever MRI imaging reveals typical white matter abnormalities. Furthermore, this case report emphasizes the importance of CMB assessment, appropriate blood pressure control, and cautious assessment of the risk-benefits of antiplatelet medication in patients with CADASIL.     

Prevalence and clinical characteristics of cortical superficial siderosis in patients with acute stroke

Cortical superficial siderosis (cSS) is a pathologic and radiologic diagnosis of hemosiderin deposition in subpial brain layers. However, cSS has not been fully studied in patients with acute stroke. Here, we investigated the prevalence of cSS in patients with acute stroke and analyzed the relationship between cSS and different clinical and neuroimaging characteristics. From September 2014 through June 2016, consecutive patients with acute stroke who were admitted to our department were retrospectively investigated. We analyzed the prevalence of cSS and the associations between cSS and risk factors, the topographic distribution of cerebral microbleeds (CMBs), and the severity of white matter lesions (WMLs). In total, 739 patients (589 patients with ischemic stroke/transient ischemic stroke [IS/TIA] and 150 with intracerebral hemorrhage [ICH]; mean age, 71.4 years) were enrolled. We identified cSS in six (1.0%) patients with IS/TIA and seven (4.7%) patients with ICH. The presence of cSS was associated with ICH (P < 0.0001), WMLs (P = 0.0105), and lobar and non-lobar CMBs (both P < 0.0001); no associations between cSS and age, sex, cardiovascular risk factors, IS subtype classification, or antiplatelet and anticoagulant therapy were found. In a multivariable logistic regression analysis, high numbers of lobar CMBs (≥ 2; odds ratio, 11.03; 95% confidence interval, 2.03–205.40; P = 0.0029) were independently associated with cSS. Furthermore, cSS was often located near lobar CMBs. Our results suggest that cSS is prevalent in ICH and is independently associated with lobar CMBs; however, no associations between cSS and other risk factors or comorbidities were observed.     

磁共振成像脑微出血与抗栓治疗脑出血相关

目的 观察脑微出血是否与抗栓治疗颅内出血(ICH)相关。方法 选择本院从2005年6月至2010年6月共43例抗栓治疗的脑出血患者,选择同期年龄、性别、高血压史相匹配的非抗栓治疗的脑出血患者及无脑出血史的抗栓药物使用患者作对照。结果 抗栓治疗脑出血组较无脑出血史的抗栓药物组更易发生脑微出血[31/43(72.1％)与12/57(21.1％),x2=6.731,P=0.011],抗栓治疗脑出血组较非抗栓治疗脑出血组更易发生脑微出血[31/43 (72.1％)与17/48 (35.4％),x2 =4.971,P=0.030]。脑叶微出血在抗栓治疗脑出血组为27/43(62.8％),而在非抗栓治疗脑出血组为19/48 (39.6％),两组比较差异有统计学意义(x2=4.019,P=0.042)。脑微出血数目是抗栓治疗脑出血的危险因素（OR=1.38,95％CI 1.07～1.71,t=0.806,P=0.021）。结论 脑微出血与抗栓治疗脑出血相关。     

缺血性卒中患者二级预防相关脑微出血形成的危险因素分析

目的 探讨缺血性卒中患者二级预防时脑微出血(CMBs)形成的危险因素,为脑血管病的防治提供依据和指导.方法 收集明确诊断为急性缺血性卒中的患者,且在应用抗血小板聚集药物治疗4 d内完成磁敏感加权成像(SWI)检查,对纳入的患者随访12个月,12个月后复查SWI,记录随访前后CMBs的数量和部位.结果 共纳入了94例患者,其中发现伴CMBs患者50(53.2%)例,经二分类Logistics回归分析发现:高血压病史(OR=1.2,95%CI=1.07~1.61,P=0.004)、年龄(OR=2.2,95%CI=1.25~3.92,P=0.006)是CMBs形成的独立危险因素,且年龄每增加10岁,CMBs患病率增加2.2倍,经ROC曲线分析发现:年龄曲线下面积为0.695(95%CI=0.588~0.802),年龄预测CMBs的最佳cutoff值为62岁,当患者年龄≥62岁时,发生CMBs的风险明显增高.在12个月的随访中有22例患者复查SWI检查,发现新增CMBs病灶33个,经Wilcoxon非参数配对秩和检验结果显示随访后CMBs数量的中位数是2.5个,基线时是1个(Z=-3.1,P=0.002),随访前后CMBs数量差异有统计学意义.结论 对于年龄≥62岁、高血压病史、规律应用抗血小板聚集药物的缺血性卒中患者,应定期监测CMBs的数量和部位,以指导二级预防治疗方案.     

脑微出血影像学分类与血浆血管内皮生长因子水平及载脂蛋白E基因分型的关系研究

目的基于载脂蛋白E(apolipoproteinE,ApoE)基因分型探讨脑微出血(cerebralmicrobleeds,CMBs)影像学分类与血浆血管内皮生长因子(vascular endothelial growth factor,VEGF)水平的关系,为CMBs预警筛查提供有效的生物标志物。方法选择2014年8月-2017年8月在青岛大学附属医院黄岛分院及青岛大学附属威海市中心医院住院治疗的急性脑梗死患者,根据是否存在CMBs分为CMBs组和非CMBs组。对所有脑梗死患者的性别、年龄、简易精神状态评估量表(mini-mentalstateexamination,MMSE)评分、NIHSS评分、高血压病、收缩压、糖尿病、降压药物、抗凝及抗血小板药物使用等因素进行记录。根据CMBs的分布位置不同,参照CMBs解剖评定量表将CMBs分为深部CMBs、脑叶CMBs、幕下CMBs、混合型CMBs。为方便研究,本研究将幕下CMBs归类于深部CMBs。为避免混合型CMBs对研究的干扰,予以剔除。采用ApoE基因分型试剂盒对各组患者进行ApoE基因分型。采用人VEGFQuantikineELISA试剂盒检测血浆VEGF浓度。校正混杂因素使用Logistic分析VEGF与总体CMBs及CMBs不同影像学类型的关系。结果经筛查发现CMBs99例,包括被排除的7例混合型分布(脑叶+深部或脑叶+幕下)的CMBs患者。CMBs组血浆VEGF水平高于非CMBs组(P=0.005)。脑深部CMBs组血浆VEGF水平高于非CMBs组(P=0.009)。高水平的血浆VEGF是CMBs的危险因素(OR 1.59,95%CI 1.02～2.47,P=0.005)。在脑深部CMBs患者中,血浆VEGF水平与ApoE基因型存在交互作用(P=0.01)。在携带ApoEε3/ε3患者中,血浆VEGF水平每增加一个标准差对于脑深部CMBs的多因素校正OR值是0.90(95%CI 0.49～1.20,P=0.73);在ApoEε2或ε4患者中,每增加一个标准差对脑深部CMBs多因素校正OR值是2.83(95%CI1.31～6.10,P=0.008)。结论脑深部CMBs与高水平血浆VEGF有关。血浆VEGF与CMBs的风险联系可能存在ApoE基因型依赖。     

Multiple Cerebral Microbleeds: Mri Marker of a Diffuse Hemorrhage–Prone State

BACKGROUND: Recent reports have indicated that cerebral microbleeds (CMBs) detected on gradient-echo (GRF) magnetic resonance imaging may be a risk factor for therapy related intracranial hemorrhages (ICHs). CASE DESCRIPTION: The authors describe 3 patients with multiple CMBs in whom ICHs occurred either after tissue plasminogen activator administration or after the initiation of antiplatelet therapy. Hemorrhages occurred in brain areas with normal appearances on GRE imaging and remote from the CMBs. CONCLUSION: Multiple CMBs may signal a diffuse hemorrhage-prone vasculopathy.     

缺血性脑血管病患者脑微出血相关因素及其对抗血小板单药治疗的影响分析

目的 研究缺血性脑血管病患者脑微出血（CMB）危险因素及其对抗血小板单药治疗的影响。方法 选取2018年1月至2018年6月该院神经内科接受抗血小板单药治疗的急性缺血性脑血管病患者300例为样本,入院后采集基本资料并完善相关检查,根据梯度回波T2^*加权成像（GRE-T2^*WI）检查结果将患者分为CMB组（176例）和非CMB组（124例）,均给予抗血小板聚集治疗,比较两组临床资料及治疗1年内再发梗死、脑出血和病死率,分析影响CMB发病的危险因素以及CMB对抗血小板单药治疗的影响。结果 高龄、高血压、肥胖、脑卒中病史、ACI和脑白质疏松为CMB发生的危险因素（P<0.05）。CMB组和非CMB组抗血小板单药治疗期间脑出血率分别为14.20%和6.45%,差异有统计学意义（P<0.05）。轻度组、中度组和重度组脑出血率分别为9.18%、10.64%和35.48%,差异有统计学意义（P<0.05）。不同部位CMB患者抗血小板单药治疗期间再发脑梗死、脑出血及病死率比较,差异无统计学意义（P>0.05）。结论 高龄、高血压、肥胖、脑卒中病史、ACI及脑白质疏松为缺血性脑血管疾病合并CMB的危险因素。CMB可导致抗血小板单药治疗期间脑出血风险增加,重度CMB者更甚。     

Cerebral microbleeds in CADASIL

BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary arteriopathy leading to recurrent cerebral infarcts and dementia. Intracerebral hemorrhage (ICH) has been described sporadically in patients with CADASIL, suggesting that the affected arteries in CADASIL are not bleed-prone. However, the presence of cerebral microbleeds, which often remain undetected on conventional MRI, has not been determined in CADASIL. OBJECTIVE: To determine whether cerebral vessels in patients with CADASIL are prone to microbleeding. METHODS: T2*-weighted gradient echo MRI, which is highly sensitive for visualizing microbleeds, was performed in patients with CADASIL and their family members (n = 63). Known risk factors for ICH were determined for all individuals. On an exploratory basis, the presence of cerebral microbleeds was correlated with demographic variables, vascular risk factors, disease progression, ischemic MR lesions, and genotype. RESULTS: Cerebral microbleeds were present in 31% of symptomatic CADASIL mutation carriers, predominantly in the thalamus. Vascular risk factors such as hypertension did not account for the microbleeds in these patients. Factors associated with microbleeds were age (p = 0.008), Rankin disability score (p = 0.017), antiplatelet use (p = 0.025), number of lacunae on MRI (p = 0.009), and the Arg153Cys Notch3 mutation (p = 0.017). After correction for age, only the Arg153Cys mutation remained significantly associated with the presence of microbleeds. CONCLUSION: Patients with CADASIL have an age-related increased risk of intracerebral microbleeds. This implies that they may have an increased risk for ICH, which should be taken into account in CADASIL diagnosis and patient management.     

Cerebral Microbleeds are Associated with Higher Mortality Among Ischemic Stroke Patients

Background

Several studies have shown that cerebral microbleeds (CMBs) increase the risk of long-term stroke-related mortality. The purpose of this study was to determine if the existence and burden of CMBs are a predictor of in-hospital death among patients with acute ischemic stroke (AIS).

伴脑出血史的缺血性卒中患者使用抗血小板药物二级预防的调查

目的 通过结局调查分析既往有脑出血史的缺血性卒中患者使用抗血小板药物(antiplatelet drugs,APD)的状况以及使用APD对再发脑出血和再发脑梗死的影响.方法 随访我院既往有过脑出血的脑梗死患者的单中心、回顾性队列研究.统计学方法采用生存曲线及Logistic回归分析APD对既往有过脑出血患者缺血性卒中二级预防结局的影响.结果 既往有过脑出血的缺血性卒中合并心房颤动和心肌梗死的患者在心内科就诊时更易接受服用APD.既往有过脑出血患者缺血性卒中二级预防中APD没有增加再发脑出血(OR=1.149,95%CI0.376～3.513,P=0.808);未良好控制的高血压和脑叶出血是再发脑出血的危险因素;APD的使用能明显降低再发脑梗死的发生(OR=0.410,95%CI0.203～0.826,P=0.013).既往有过脑出血的缺血性卒中患者服用APD再发脑出血间隔时间均值为39个月,未服APD患者为45个月(X2=1.257,P=0.262).既往有过脑出血的缺血性卒中患者服用APD再发脑梗死间隔时间均值为42个月,末服APD患者为22个月(X2=14.315,P=0.001).结论 既往有过脑出血的缺血性卒中患者,通过APD进行缺血性卒中二级预防可获益,再发肭出血未见增多.考虑到本调查中脑叶出血和高血压控制不良容易再发脑出血,使用APD时把血压控制在正常范围并排除既往有过脑叶出血的病例,也许是更为安全的选择.     

抗凝及抗血小板药物治疗与颅内出血的关系分析

目的　探讨口服抗凝及抗血小板药物治疗有关颅内出血的危险因素 ,分析与此相关的临床和放射学资料。方法　所有病例分为 3组 ,1组为与抗凝及抗血小板有关的颅内出血病人 ,对病人CT表现、临床症状、血小板、凝血因子筛选试验 ,出血部位和体积 ,住院 3 0d死亡率进行分析。 2组随机选取同期住院的自发性脑出血病人 ,方法同上。 3组为长期口服抗凝及抗血小板药物而无颅内出血者。结果　 1组与 2组比较 ,前者有卒中史者比较高 ,出血体积大 ,临床表现重 ,预后差。 1组与 3组相比较 ,抗凝及抗血小板治疗时间短 ,血小板数减少 ,凝血酶原时间、凝血酶时间延长。结论　抗凝及抗血小板治疗有关的颅内出血比自发性颅内出血体积大 ,死亡率高 ,抗凝及抗血小板药物过量是主要危险因素。对抗凝及抗血小板治疗病人应定期进行止血功能检测 ,尤其在第1年 ,有助于减少颅内出血的发生     

Intracerebral hemorrhages in CADASIL

Intracerebral hemorrhage (ICH) has been described only sporadically for patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). However, cerebral microbleeds (CMBs) were found in 31% to 69% of the patients with CADASIL, and this predicted an increased risk of ICH. In this study, the authors found that 25% of the symptomatic patients with CADASIL had ICHs, and their development was closely related to the number of CMBs.     

New cerebral microbleeds in ischemic stroke patients on warfarin treatment: Two-year follow-up

Objective

Cerebral microbleeds (CMBs) are known to be indicative of bleeding-prone microangiopathy. Little is known about the significance of CMBs in anticoagulated patients. We determined the frequency of new CMBs in ischemic stroke patients who had been receiving warfarin treatment for 2 years.

Methods

A total of 204 ischemic stroke patients on warfarin therapy for 2 years underwent a repeat MRI. We compared demographic features, vascular risk factors, and radiological findings of patients with and without new CMBs.

Results

New CMBs on gradient-echo MRI were found in 29 of 204 patients (10%). Of 35 patients who had CMBs in the original study, 9 developed new CMBs after 2 years (26%), compared with 20 of the 169 patients (12%) who did not have CMBs at baseline (p = 0.03). Patients with new CMBs were older than patients without CMBs (p = 0.04), and the frequency of leukoaraiosis was significantly higher (p = 0.02). The mean duration of warfarin treatment was not significantly different between the patients with and without new CMBs (p = 0.28).

Conclusion

This longitudinal study suggested that the presence of CMBs at baseline increased the frequency of new CMBs in patients on warfarin therapy.     

Cerebral small vessel disease burden and functional and radiographic outcomes in intracerebral hemorrhage

Objective

To examine the effect of individual cerebral small vessel disease (CSVD) markers and cumulative CSVD burden on functional independence, ambulation and hematoma expansion in spontaneous intracerebral hemorrhage (ICH).

Methods

Retrospective analysis of prospectively collected data from an observational study of consecutive patients with spontaneous ICH, brain MRI within 1 month from ictus, premorbid modified Rankin Scale (mRS) score?≤?2, available imaging data and 90-day functional status in a tertiary academic center. Functional outcomes included 90-day functional independence (mRS?≤?2) and independent ambulation; radiographic outcome was hematoma expansion (>?12.5 ml absolute or >?33% relative increase in ICH volume). We identified the presence and burden of individual CSVD markers (cerebral microbleeds (CMBs), enlarged perivascular spaces, lacunes, white matter hyperintensities) and composite CSVD burden score and explored their association with outcomes of interest in multivariable models adjusting for well-established confounders.

Results

111 patients were included, 65% lobar ICH, with a median volume 20.8 ml. 43 (38.7%) achieved functional independence and 71 (64%) independent ambulation. In multivariable adjusted models, there was higher total CSVD burden (OR 0.61, 95% CI 0.37–0.96, p?=?0.03) and CMBs presence (OR 0.32, 95% CI 0.1–0.88, p?=?0.04) remained independently inversely associated with functional independence. Individual CSVD markers or total CSVD score had no significant relation with ambulation and ICH expansion. Larger ICH volume and deep ICH location were the major determinants of lack of independent ambulation.

Conclusions

Our findings suggest that in ICH patients without previous functional dependence, total CSVD burden and particularly presence of CMBs significantly affect functional recovery. The latter is a novel finding and merits further exploration.

     

动态动脉硬化指数、非杓型血压与急性缺血性脑卒中患者脑微出血的相关性研究

目的 探讨急性缺血性脑卒中患者动态动脉硬化指数(ambulatory arterial stiffness index,AASI)、非杓型血压与脑微出血(cerebral microbleeds, CMBs)的相关性。方法 回顾性连续纳入2014年1月～2015年12月急性缺血性卒中患者104例,根据头颅SWI检查显示是否发生CMBs将患者分为CMBs组(42例)和非CMBs组(62例),比较2组患者的临床特点,根据24 h动态血压(ABPM)监测计算AASI,以夜间平均动脉压下降率≥10%为正常杓型血压,<10%则为血压昼夜节律异常,即非杓型血压,分析急性缺血性卒中患者AASI、非杓型血压与脑微出血的相关性。结果 CMBs组年龄、抗血小板聚集药物使用、AASI、糖化血红蛋白、非杓型血压、既往脑卒中史与非CMBs组比较有明显差异(P<0.05),在多因素logistic回归分析中AASI和非杓型血压、年龄是影响CMBs发生的独立危险因素(P<0.05)。Spearman等级相关分析显示CMBs严重程度与AASI(r=0.290,P=0.001)及非杓型血压(r=0.203,P=0.013)均呈正相关。结论 年龄、AASI、非杓型血压是CMBs的重要影响因素,可作为预测CMBs的独立因素。     

Prevalence and Associated Risk Factors of Cerebral Microbleeds in Egyptian Patients with Acute Ischemic Stroke and Atrial Fibrillation

BackgroundFew studies addressed the prevalence of cerebral microbleeds (CMB) and associated risk factor profile in Egyptian ischemic cerebral stroke patients with atrial fibrillation (AF).MethodsThe prevalence of CMB was estimated in 150 cases of AF ischemic stroke patients and compared to the prevalence in 150 age- and sex-matched controls of ischemic stroke patients without AF. CMB-associated risk factors were identified by comparing AF ischemic stroke patients with and without CMB. All participants were subjected to complete general, neurological examination, and magnetic resonance imaging.ResultsThe prevalence of CMBs in ischemic stroke with and without AF was 40.7% and 49.3%, respectively. Age, hypertension, diabetes mellitus, past history of stroke, antiplatelet, anticoagulant, National Institutes of Health Stroke Scale, CHA₂DS₂VASc, and white matter lesions (WML) were significant risk factors associated with CMB on univariate analysis. On multivariable logistic regression analysis, age (odds ratio [OR] 1.1, confidence interval [CI] 1.02-1.13), hypertension (OR 3.2, CI 1.19-8.81), anticoagulant (OR 3.3, CI 1.17-9.40), and WML (OR 9.6, CI 3.49-26.3) were the only independent risk factors associated with the presence of CMBs.ConclusionsAF in ischemic stroke patients was not associated with higher prevalence of CMBs. Old age, hypertension, anticoagulant treatment, and WML were the independent risk factors associated with CMB in AF ischemic stroke patients. Our results suggest that elderly hypertensive AF ischemic stroke patients maintained on anticoagulant therapy should be screened for the incidence of CMBs and monitored regularly for the development of intracerebral hemorrhage.     

Effect of antiplatelet therapy on the incidence,prognosis, and rebleeding of intracerebral hemorrhage

Objective

Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown.

Methods

We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included “antiplatelet,” “intracerebral hemorrhage,” “cerebral microbleeds,” “hematoma expansion,” “recurrent,” and “reinitiate.” Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed.

Results

When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients’ concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future.

Conclusion

This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.