Antiplatelet use after intracerebral hemorrhage

Systematic review of observational research studying the long-term use of antithrombotic medicines following intracerebral hemorrhage

Patients with intracerebral hemorrhage frequently have indications for antithrombotic therapy. This represents a therapeutic dilemma as intracerebral hemorrhage is considered a contraindication to antithrombotic medication. Previous systematic reviews have revealed no long-term randomised studies addressing this issue. Our objective was to review observational studies describing the long-term follow-up of patients receiving antithrombotic therapy following intracerebral hemorrhage. Searches were conducted in MEDLINE and EMBASE from 1984 to 2008 for any observational studies detailing use of antithrombotic treatments in patients with intracerebral hemorrhage. Included studies must have had follow-up extending beyond discharge. The primary endpoint was recurrent intracerebral hemorrhage. Secondary endpoints were ischemic events and serious vascular events. 1,301 articles were reviewed: two epidemiological studies and six case series met the inclusion criteria. These described a total of 46 subjects receiving antiplatelet agents (from one study) and 42 patients receiving oral anticoagulants (from one study and six case-series). For patients receiving subsequent aspirin there were seven recurrent intracerebral hemorrhages and four subsequent thrombo-occulsive events. Amongst patients restarting oral anticoagulation there were four recurrent intracerebral bleeds and nine subsequent thrombo-occulsive events. There is a marked paucity of evidence to guide clinicians when planning the long-term management of patients with intracerebral hemorrhage and cogent indications for antithrombotic therapy. Published guidance addressing this issue is not evidence based. In the continued absence of randomised studies addressing antithrombotic use following intracerebral hemorrhage, there is a clear requirement for further high quality observational data on the clinical impact of antithrombotic therapy in this important patient group.

Cerebral microbleeds: a guide to detection and interpretation

Cerebral microbleeds (CMBs) are increasingly recognised neuroimaging findings in individuals with cerebrovascular disease and dementia, and in normal ageing. There has been substantial progress in the understanding of CMBs in recent years, particularly in the development of newer MRI methods for the detection of CMBs and the application of these techniques to population-based samples of elderly people. In this Review, we focus on these recent developments and their effects on two main questions: how CMBs are detected, and how CMBs should be interpreted. The number of CMBs detected depends on MRI characteristics, such as pulse sequence, sequence parameters, spatial resolution, magnetic field strength, and image post-processing, emphasising the importance of taking into account MRI technique in the interpretation of study results. Recent investigations with sensitive MRI techniques have indicated a high prevalence of CMBs in community-dwelling elderly people. We propose a procedural guide for identification of CMBs and suggest possible future approaches for elucidating the role of these common lesions as markers for, and contributors to, small-vessel brain disease.

Effect of statins on intracerebral hemorrhage outcome and recurrence

BACKGROUND AND PURPOSE

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been associated with improved outcome after ischemic stroke and subarachnoid hemorrhage but an increased risk of incident intracerebral hemorrhage (ICH). We investigated (1) whether statin use before ICH was associated with functional independence at 90 days, and (2) whether survivors exposed to statins after ICH had an increased risk of recurrence.

METHODS

We analyzed 629 consecutive ICH patients with 90-day outcome data enrolled in a prospective cohort study between 1998 to 2005. Statin use was determined by patient interview at the time of ICH and supplemented by medical record review. Independent status was defined as Glasgow Outcome Scale 4 or 5. ICH survivors were followed by telephone interview every 6 months.

RESULTS

Statins were used by 149/629 (24%) before ICH. There was no effect of pre-ICH statin use on the rates of functional independence (28% versus 29%, P=0.84) or mortality (46% versus 45%, P=0.93). Medical comorbidities and warfarin use were more common in statin users. Hematoma volumes were similar (median 28 cm(3) in pre-ICH statin users compared to 22 cm(3) in nonusers, P=0.18). The multivariable-adjusted odds ratio for independent status in pre-ICH statin users was 1.16 (95% CI 0.65 to 2.10, P=0.62). ICH survivors treated with statins after discharge did not have a higher risk of recurrence (adjusted HR 0.82, 95% CI 0.34 to 1.99, P=0.66).

CONCLUSIONS

Pre-ICH statin use is not associated with improved ICH functional outcome or mortality. Post-ICH statin use is not associated with an increased risk of ICH recurrence.

[Anticoagulation for stroke prevention. An update]

Given the projected rising prevalence of atrial fibrillation in the near future, an increasing number of older patients will have to be treated in order to prevent stroke and systemic embolism. This article summarizes recent developments in antithrombotic treatment and risk stratification for patients with atrial fibrillation and intends to abate the still prevailing reluctance towards anticoagulation in elderly patients.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Sporadic cerebral amyloid angiopathy--an important cause of cerebral haemorrhage in older people

Cerebral amyloid angiopathy (CAA) is an important cause of primary intracerebral haemorrhage (PICH) in older people, accounting for approximately 10% of all types of PICH. The amount of amyloid deposition in the vessels and vasculopathic changes determine the propensity to PICH. The risk factors of CAA include advanced age and the presence of certain alleles of apolipoprotein E. There are no specific clinical features of CAA-related PICH, although lobar, recurrent or multiple simultaneous haemorrhages in older patients should raise suspicion of its diagnosis. A definitive diagnosis of CAA requires pathological examination of the affected tissue. However, with modern imaging techniques, it is possible to make a diagnosis of 'probable CAA' in patients presenting with PICH. Gradient-echo magnetic resonance imaging is a sensitive, non-invasive technique for identifying small haemorrhages in life. Currently, there is no specific treatment available for CAA. Recent advances in the immunopathology and pathogenesis of CAA are expected to help in developing specific anti-amyloid therapy.

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Cerebral Microhemorrhage

Background and Purpose— With the advent of modern MRI imaging techniques, cerebral microhemorrhages have been increasingly recognized on gradient-echo (GE) or T2*-weighted MRI sequences in different populations. However, in clinical practice, their diagnostic value, associated risk, and prognostic significance are often unclear. This review summarizes the pathophysiology, differential diagnosis, epidemiology, and clinical significance of cerebral microhemorrhages.

Summary of Review— Focal areas of signal loss on GE MRI imaging pathologically represent focal hemosiderin deposition associated with previous hemorrhagic events. Cerebral microhemorrhages have been noted in healthy elderly, ischemic cerebrovascular disease, intracerebral hemorrhage (ICH), cerebral amyloid angiopathy (CAA), and in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Microhemorrhages have been associated with older age, hypertension, smoking, white matter disease, lacunar infarcts, previous ischemic stroke, or ICH. In CAA, microhemorrhages predict both the risk of recurrent lobar ICH and future clinical decline. In patients with ischemic cerebrovascular disease, microhemorrhage number and location may be associated with executive dysfunction and may predict the occurrence of ICH and lacunar infarction.

Conclusions— When cerebral microhemorrhages are diagnosed on MRI, conclusions regarding their significance and associated risks should be made based on the population examined. Further studies to characterize the associated risks of cerebral microhemorrhages in different stroke populations are needed to use this new imaging marker in therapeutic decisions.