Previous chronic symptomatic and asymptomatic cerebral hemorrhage in patients with acute ischemic stroke

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Abstract

Purpose

Identifying previous chronic cerebral hemorrhage (PCH), especially asymptomatic cases in patients with ischemic stroke, is essential for proper antithrombotic management. The study aimed to further clarify the prevalence of PCH and the associated factors in patients with acute ischemic stroke using multi-modal neuroimaging including susceptibility-weighted MR imaging (SWI).

Methods

This was a retrospective cross-sectional study of 382 patients with acute ischemic stroke. All patients underwent 3.0-T MRI for cranial SWI, 1.5-T or 3.0-T conventional cranial MRI, and cranial CT. Patients found with PCH were matched 1:4 with patients without PCH. Clinical manifestation, computed tomography, conventional cranial MRI, and cranial SWI were used to determine PCH. Clinical and neuroimaging findings between the patients with symptomatic vs. asymptomatic PCH were compared.

Results

Thirty-six patients (36/382, 9.4%) were determined to have had a PCH. Of these 36 patients, 17 (17/36, 47.2%, or 17/382, 4.5%) had asymptomatic PCH. Multivariable analysis showed that serum total cholesterol (OR = 0.510, 95%CI 0.312–0.832, P = 0.007), cerebral microbleeds (OR = 6.251, 95%CI 2.220–17.601, P = 0.001), and antithrombotic drugs history (OR = 3.213, 95%CI 1.018–10.145, P = 0.047) were independently associated with PCH. Asymptomatic PCH had similar clinical and neuroimaging characteristics with symptomatic PCH.

Conclusion

PCH is not uncommon in acute ischemic stroke patients. Total serum cholesterol, cerebral microbleeds on SWI, and history of antithrombotic drugs were independently associated with PCH in patients with acute ischemic stroke. Asymptomatic PCH, which is easier to be missed and has similar characteristics with symptomatic PCH, should draw much attention.

Electronic supplementary material

The online version of this article (10.1007/s00234-018-2141-y) contains supplementary material, which is available to authorized users.

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Most cited references 16

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Imaging cerebral microbleeds using susceptibility weighted imaging: one step toward detecting vascular dementia.

S Boikov, W Kirsch, E. Haacke … (2009)

To monitor changes in the number of cerebral microbleeds (CMBs) in a longitudinal study of healthy controls (HC) and mild-cognitively impaired (MCI) patients using susceptibility weighted imaging (SWI). SWI was used to image 28 HC and 75 MCI patients annually at 1.5 Tesla over a 4-year period. Magnitude and phase data were used to visualize CMBs for the first and last scans of 103 subjects. Preliminary analysis revealed that none of the 28 HC had more than three CMBs. In the 75 MCI patients, five subjects had more than three CMBs in both first and last scans, while one subject had more than three bleeds only in the last scan. In five of these six MCI patients, the number of CMBs increased over time and all six went on to develop progressive cognitive impairment (PCI). Of the 130 total CMBs seen in the last scans of the six MCI cases, most were less than 4 mm in diameter. SWI can reveal small CMBs on the order of 1 mm in diameter and this technique can be used to follow their development longitudinally. Monitoring CMBs may be a means by which to evaluate patients for the presence of microvascular disease that leads to PCI. (c) 2009 Wiley-Liss, Inc.

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Risk of intracranial hemorrhage (RICH) in users of oral antithrombotic drugs: Nationwide pharmacoepidemiological study

Sasha Gulati, Ole Solheim, Sven M. Carlsen … (2018)

Background The risks of intracranial haemorrhage (ICH) associated with antithrombotic drugs outside clinical trials are gaining increased attention. The aim of this nationwide study was to investigate the risk of ICH requiring hospital admission in users of antithrombotic drugs. Methods and findings Data from the Norwegian Patient Registry and Norwegian Prescription Database were linked on an individual level. The primary outcome was incidence rates of ICH associated with use of antithrombotic drugs. Secondary endpoints were risk of ICH and fatal outcome following ICH assessed by Cox models. Among 3,131,270 individuals ≥18 years old observed from 2008 through 2014, there were 729,818 users of antithrombotic medications and 22,111 ICH hospitalizations. Annual crude ICH rates per 100 person-years were 0.076 (95% CI, 0.075–0.077) in non-users and 0.30 (95% CI, 0.30–0.31) in users of antithrombotic medication, with the highest age and sex adjusted rates observed for aspirin-dipyridamole plus clopidogrel (0.44; 95% CI, 0.19–0.69), rivaroxaban plus aspirin (0.36; 95% CI, 0.16–0.56), warfarin plus aspirin (0.34; 95% CI, 0.26–0.43), and warfarin plus aspirin and clopidogrel (0.33; 95% CI, 0.073–0.60). With no antithrombotic medication as reference, the highest adjusted hazard ratios (HR) for ICH were observed for aspirin-dypiridamole plus clopidogrel (6.29; 95% CI 3.71–10.7), warfarin plus aspirin and clopidogrel (4.38; 95% CI 2.71–7.09), rivaroxaban plus aspirin (3.82; 95% CI, 2.46–5.95), and warfarin plus aspirin (3.40; 95% CI, 2.99–3.86). All antithrombotic medication regimens were associated with an increased risk of ICH, except dabigatran monotherapy (HR 1.20; 95% CI, 0.88–1.65) and dabigatran plus aspirin (HR 1.79; 95% CI, 0.96–3.34). Fatal outcome within 90 days was more common in users (2,603 of 8,055) than non-users (3,228 of 14,056) of antithrombotic medication (32.3% vs 23.0%, p<0.001), and was associated with use of warfarin plus aspirin and clopidogrel (HR 2.89; 95% CI, 1.49–5.60), warfarin plus aspirin (HR 1.37; 95% CI, 1.11–1.68), aspirin plus clopidogrel (HR 1.30; 95% CI, 1.05–1.61), and warfarin (HR 1.19; 95% CI, 1.09–1.31). Increased one-year mortality was observed in users of antithrombotic medication following hemorrhagic stroke, subdural hemorrhage, subarachnoid hemorrhage, and traumatic ICH (all p<0.001). Limitations include those inherent to observational studies including the inability to make causal inferences, certain assumptions regarding drug exposure, and the possibility of residual confounding. Conclusions The real-world incidence rates and risks of ICH were generally higher than reported in randomized controlled trials. There is still major room for improvement in terms of antithrombotic medication safety (clinicaltrials.gov NCT02481011).

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Antithrombotic Treatment Following Intracerebral Hemorrhage in Patients With and Without Atrial Fibrillation.

Marie Eriksson, Signild Åsberg, Aase Wisten … (2015)

Patients who survive intracerebral hemorrhage (ICH) often have compelling indications for anticoagulant and antiplatelet medication. This nationwide observational study aimed to determine the extent and predictors of antithrombotic treatment after ICH in Sweden.

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Author and article information

Contributors

Jian-Ren Liu:

ORCID: http://orcid.org/0000-0002-2319-7788

021-23271699-5597 , liujr021@sjtu.edu.cn

Journal

Journal ID (nlm-ta): Neuroradiology

Journal ID (iso-abbrev): Neuroradiology

Title: Neuroradiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0028-3940

ISSN (Electronic): 1432-1920

Publication date (Electronic): 28 November 2018

Publication date PMC-release: 28 November 2018

Publication date (Print): 2019

Volume: 61

Issue: 1

Pages: 103-107

Affiliations

[1 ]ISNI 0000 0004 0368 8293, GRID grid.16821.3c, Department of Neurology, Comprehensive Stroke Center, Shanghai Ninth People’s Hospital, , Shanghai Jiao Tong University School of Medicine, ; 639 Zhizaoju Road, Huangpu District, Shanghai, 200011 China

[2 ]ISNI 0000 0004 0368 8293, GRID grid.16821.3c, Clinical Research Center, Shanghai Ninth People’s Hospital, , Shanghai Jiao Tong University School of Medicine, ; Shanghai, 200011 China

[3 ]ISNI 0000 0004 0368 8293, GRID grid.16821.3c, Department of Radiology, Shanghai Ninth People’s Hospital, , Shanghai Jiao Tong University School of Medicine, ; Shanghai, 200011 China

Author information

Jian-Ren Liu http://orcid.org/0000-0002-2319-7788

Article

Publisher ID: 2141

DOI: 10.1007/s00234-018-2141-y

PMC ID: 6336746

PubMed ID: 30488255

SO-VID: eedd5f3c-5627-4c4c-aaf5-12b6faedff2d

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 29 September 2018

Date accepted : 19 November 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100001809, National Natural Science Foundation of China;

Award ID: 31400838

Award ID: 81271302

Award Recipient : Guo-Hong Cui Jian-Ren Liu

Funded by: research innovation project from Shanghai municipal science and technology commission

Award ID: 14JC1404300