Cerebral Microbleeds and Macrobleeds: Should They Influence Our Recommendations for Antithrombotic Therapies?
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STROKE (C SILA, SECTION EDITOR)
Cerebral Microbleeds and Macrobleeds: Should They Influence Our Recommendations for Antithrombotic Therapies? Kellen E. Haley & Steven M. Greenberg & M. Edip Gurol
Published online: 13 October 2013 # Springer Science+Business Media New York 2013
Abstract Intracerebral hemorrhage (ICH, or macrobleeds) and cerebral microbleeds—smaller foci of hemosiderin deposits commonly detected by magnetic resonance imaging of older adults with or without ICH—are both associated with an increased risk of future ICH. These hemorrhagic pathologies also share risk factors with ischemic thromboembolic conditions that may require antithrombotic therapy, requiring specialists in cardiology, internal medicine, and neurology to weigh the benefits vs hemorrhagic risks of antithrombotics in individual patients. This paper will review recent advances in our understanding of hemorrhage prone cerebrovascular pathologies with a particular emphasis on use of these markers in decision making for antithrombotic use. Keywords Intracerebral hemorrhage . Cerebral . Microbleed . Macrobleed . Anticoagulation . Antithrombotic therapy . Stroke prevention . Leukoaraiosis . Sulcal Siderosis Introduction Intracranial hemorrhages are classified based on the primarily affected intracranial compartment and they include
This article is part of the Topical Collection on Stroke K. E. Haley Boston University, Boston, MA, USA e-mail: [email protected] K. E. Haley : S. M. Greenberg : M. E. Gurol Hemorrhagic Stroke Research Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA S. M. Greenberg e-mail: [email protected] M. E. Gurol (*) Massachusetts General Hospital, Stroke Service, 175 Cambridge Street #300, Boston, MA 02114, USA e-mail: [email protected]
intraparenchymal (IPH), intraventricular (IVH), subarachnoid (SAH), subdural, and epidural hemorrhages. Subdural and epidural hemorrhages are most commonly related to head trauma whereas SAH generally arise from ruptured cerebral aneurysms. This review will primarily focus on spontaneous intracerebral hemorrhage (ICH), a common type of stroke including IPH and IVH that occurs in the absence of gross vascular pathology or trauma. ICH makes up 8 %–18 % of all strokes based on published registries [1, 2]. Bleeding within the brain parenchyma is classified as a macrobleed if it is greater than 5–10 mm in largest diameter as seen on head computed tomography (CT) or magnetic resonance imaging (MRI) (Fig. 1a) [3]. IPH and IVH are usually symptomatic with the acute onset of headache, altered consciousness, and focal neurologic deficits. Most recent population based estimates suggest an overall ICH incidence of 24.6 per 100,000 person-years [4••]. Intracerebral hemorrhage is a devastating condition, as it carries a 1-month case fatality rate of 40 % [4••] and a 1-year fatality of more than 50 % [2]. With only 20 % of patients independent at 6 months [2], ICH creates a heavy financial burden as well. Recent studies show that initial hospital cost
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