Andreas Charidimou1, Christopher Karayiannis2, Tae-Jin Song2, Dilek Necioglu Orken2, Vincent Thijs2, Robin Lemmens2, Jinkwon Kim2, Su Mei Goh2, Thanh G Phan2, Cathy Soufan2, Ronil V Chandra2, Lee-Anne Slater2, Shamir Haji2, Vincent Mok2, Solveig Horstmann2, Kam Tat Leung2, Yuichiro Kawamura2, Nobuyuki Sato2, Naoyuki Hasebe2, Tsukasa Saito2, Lawrence K S Wong2, Yannie Soo2, Roland Veltkamp2, Kelly D Flemming2, Toshio Imaizumi2, Velandai Srikanth2, Ji Hoe Heo2. 1. From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea. andreas.charidimou.09@ucl.ac.uk. 2. From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea.
Abstract
OBJECTIVES: To assess the association between cerebral microbleeds (CMBs) and future spontaneous intracerebral hemorrhage (ICH) risk in ischemic stroke patients with nonvalvular atrial fibrillation (AF) taking oral anticoagulants. METHODS: This was a meta-analysis of cohort studies with >50 patients with recent ischemic stroke and documented AF, brain MRI at baseline, long-term oral anticoagulation treatment, and ≥6 months of follow-up. Authors provided summary-level data on stroke outcomes stratified by CMB status. We estimated pooled annualized ICH and ischemic stroke rates from Poisson regression. We calculated odds ratios (ORs) of ICH by CMB presence/absence, ≥5 CMBs, and CMB topography (strictly lobar, mixed, and strictly deep) using random-effects models. RESULTS: We established an international collaboration and pooled data from 8 centers including 1,552 patients. The crude CMB prevalence was 30% and 7% for ≥5 CMBs. Baseline CMB presence (vs no CMB) was associated with ICH during follow-up (OR 2.68, 95% confidence interval [CI] 1.19-6.01, p = 0.017). Presence of ≥5 CMB was related to higher future ICH risk (OR 5.50, 95% CI 2.07-14.66, p = 0.001). The pooled annual ICH incidence increased from 0.30% (95% CI 0.04-0.55) among CMB-negative patients to 0.81% (95% CI 0.17-1.45) in CMB-positive patients (p = 0.01) and 2.48% (95% CI 1.2-6.2) in patients with ≥5 CMBs (p = 0.001). There was no association between CMBs and recurrent ischemic stroke. CONCLUSIONS: The presence of CMB on MRI and the dichotomized cutoff of ≥5 CMBs might identify subgroups of ischemic stroke patients with AF with high ICH risk and after further validation could help in risk stratification, in anticoagulation decisions, and in guiding randomized trials and ongoing large observational studies.
OBJECTIVES: To assess the association between cerebral microbleeds (CMBs) and future spontaneous intracerebral hemorrhage (ICH) risk in ischemic strokepatients with nonvalvular atrial fibrillation (AF) taking oral anticoagulants. METHODS: This was a meta-analysis of cohort studies with >50 patients with recent ischemic stroke and documented AF, brain MRI at baseline, long-term oral anticoagulation treatment, and ≥6 months of follow-up. Authors provided summary-level data on stroke outcomes stratified by CMB status. We estimated pooled annualized ICH and ischemic stroke rates from Poisson regression. We calculated odds ratios (ORs) of ICH by CMB presence/absence, ≥5 CMBs, and CMB topography (strictly lobar, mixed, and strictly deep) using random-effects models. RESULTS: We established an international collaboration and pooled data from 8 centers including 1,552 patients. The crude CMB prevalence was 30% and 7% for ≥5 CMBs. Baseline CMB presence (vs no CMB) was associated with ICH during follow-up (OR 2.68, 95% confidence interval [CI] 1.19-6.01, p = 0.017). Presence of ≥5 CMB was related to higher future ICH risk (OR 5.50, 95% CI 2.07-14.66, p = 0.001). The pooled annual ICH incidence increased from 0.30% (95% CI 0.04-0.55) among CMB-negative patients to 0.81% (95% CI 0.17-1.45) in CMB-positive patients (p = 0.01) and 2.48% (95% CI 1.2-6.2) in patients with ≥5 CMBs (p = 0.001). There was no association between CMBs and recurrent ischemic stroke. CONCLUSIONS: The presence of CMB on MRI and the dichotomized cutoff of ≥5 CMBs might identify subgroups of ischemic strokepatients with AF with high ICH risk and after further validation could help in risk stratification, in anticoagulation decisions, and in guiding randomized trials and ongoing large observational studies.
Authors: Joan Martí-Fàbregas; Santiago Medrano-Martorell; Elisa Merino; Luis Prats-Sánchez; Rebeca Marín; Raquel Delgado-Mederos; Alejandro Martínez-Domeño; Pol Camps-Renom; Elena Jiménez-Xarrié; Mariluisa Zedde; Manuel Gómez-Choco; Lidia Lara; Amèlia Boix; Ana Calleja; Ana María De Arce-Borda; Yolanda Bravo; Blanca Fuentes; María Hernández-Pérez; David Cánovas; Laura Llull; Beatriz Zandio; Marimar Freijo; Ignacio Casado-Naranjo; Jordi Sanahuja; Dolores Cocho; Jerzy Krupinski; Ana Rodríguez-Campello; Ernest Palomeras; Alicia De Felipe; Marta Serrano; Elena Zapata-Arriaza; Josep Zaragoza-Brunet; Inmaculada Díaz-Maroto; Jessica Fernández-Domínguez; Aida Lago; José Maestre; Manuel Rodríguez-Yáñez; Ignasi Gich Journal: Neurology Date: 2019-04-19 Impact factor: 9.910