Highlights
- •Cerebral microbleeds raise thorny clinical questions, especially regarding future intracerebral haemorrhage risk.
- •This is a key concern in ischaemic stroke patients with AF treated with anticoagulation.
- •We present a group level meta-analysis of observational cohorts from around 1000 stroke patients.
- •We provide Class III evidence that in ischemic stroke patients with AF treated with warfarin cerebral microbleeds confer a 4-fold risk of future ICH.
- •We propose a simple data-driven anticoagulation schema.
Abstract
Introduction
Whether ischaemic stroke patients with atrial fibrillation (AF) and cerebral microbleeds
(CMBs) on MRI can be safely anticoagulated is a hotly debated topic. We performed
a systematic review and meta-analysis of published aggregate data, to investigate
the risk of subsequent intracerebral haemorrhage (ICH) based on CMBs presence in this
stroke population, generally considered for oral anticoagulation. We also suggest
a decision-making schema for anticoagulation use in this setting.
Methods
We searched PubMed for relevant observational studies. Random effects models with
DerSimonian-Laird weights were used to investigated the association between CMBs presence
at baseline MRI and ICH or ischaemic stroke during follow-up.
Results
Four studies, with slightly heterogeneous design, including 990 ischaemic stroke patients
were pooled in a meta-analysis (crude CMBs prevalence: 25%; 95%CI: 17%–33%). The median
follow-up ranged between 17 and 37 months. The future symptomatic ICH rate was 1.6% (16/990), while recurrent ischaemic
stroke rate was 5.9% (58/990). Baseline CMB presence was associated with increased
risk of symptomatic ICH during follow-up compared to patients without CMBs (OR: 4.16;
95%CI: 1.54–11.25; p = 0.005). There was no association between CMBs presence and recurrent ischaemic stroke
risk.
Conclusion
We have shown that the presence of CMBs in cohorts of ischaemic stroke patients, most
with AF on warfarin, is associated with a 4-fold increase in subsequent ICH (but not
ischaemic stroke) risk (Class III evidence). These pooled estimates are useful for
future trials design. We propose a simple data-driven anticoagulation schema which
awaits validation and refinement as new prospective data are accumulated.
Keywords
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Article info
Publication history
Published online: April 28, 2017
Accepted:
April 25,
2017
Received in revised form:
March 31,
2017
Received:
February 14,
2017
Identification
Copyright
© 2017 Elsevier B.V. All rights reserved.
