- Among older adults starting long-term oral anticoagulation for recent cardioembolic ischemic stroke, those with advanced cerebral small vessel disease, evidenced by microbleeds or moderate-to-severe white matter hyperintensities, had elevated risk for intracranial hemorrhage (ICH).
Why this matters
- Concern about ICH risk and lack of reliable predictors limits use of oral anticoagulation.
- On MRI, baseline prevalences:
- Microbleeds: 22.5%.
- Moderate/severe white matter hyperintensities: 45.1%.
- Superficial siderosis: 3.0%.
- Overall, 1.9% of patients experienced intracranial hemorrhage.
- Multivariate risk for intracranial hemorrhage elevated for patients with:
- Microbleeds (HR, 2.7; P=.031).
- Moderate/severe white matter hyperintensities (HR, 5.7; P=.006).
- Model C index: 0.76.
- Patients having both microbleeds, moderate/severe white matter hyperintensities had highest ICH rate: 3.76/100 patient-years.
- In an editorial, Luis F. Maia, MD, PhD, and Duncan Wilson, MD, PhD, write, “Available data do not support changes to the current clinical practice recommendations on anticoagulation after [ischemic stroke] based on imaging evidence for these vasculopathies.”
- Multicenter prospective cohort study of 937 patients aged >64 years with recent cardioembolic ischemic stroke who were new users of oral anticoagulation.
- Baseline MRI used to evaluate microbleeds, white matter hyperintensities, cortical superficial siderosis.
- Main outcome: ICH during mean 23.1-month follow-up.
- Funding: Fondo de Investigaciones Sanitarias Instituto de Salud Carlos III; Bristol-Myers Squibb/Pfizer.
- Possible underestimation of ICH.
- Some endpoints assessed remotely.
- Possible selection bias.