Cerebral small vessel disease and intracranial bleeding risk: Prognostic and practical significance

• Published in: International Journal of Stroke Vol. 18; no. 1; pp. 44 - 52
• Main Authors: Best, Jonathan G, Jesuthasan, Aaron, Werring, David J
• Format: Book Review Journal Article
• Language: English
• Published: London, England SAGE Publications 01.01.2023
• Subjects: Cerebral Hemorrhage - drug therapy; Cerebral Hemorrhage - therapy; Cerebral Small Vessel Diseases - drug therapy; Cerebral Small Vessel Diseases - therapy; Fibrinolytic Agents - therapeutic use; Humans; Intracranial Hemorrhages - complications; Ischemic Stroke - drug therapy; Prognosis; Risk Factors; Stroke - drug therapy; intracerebral hemorrhage; cerebral hemorrhage; Brain microbleeds; MRI; prevention; hemorrhage
• ISSN: 1747-4930; 1747-4949
• DOI: 10.1177/17474930221106014

Balancing the risks of recurrent ischemia and antithrombotic-associated bleeding, particularly intracranial hemorrhage (ICH), is a key challenge in the secondary prevention of ischemic stroke and transient ischemic attack. In hyperacute ischemic stroke, the use of acute reperfusion therapies is determined by the balance of anticipated benefit and the risk of ICH. Cerebral small vessel disease (CSVD) causes most spontaneous ICH. Here, we review the evidence linking neuroimaging markers of CSVD to antithrombotic and thrombolytic-associated ICH, with emphasis on cerebral microbleeds (CMB). We discuss their role in the prediction of ICH, and practical implications for clinical decision making. Although current observational data suggest CMB presence should not preclude antithrombotic therapy in patients with ischemic stroke or TIA, they are useful for improving ICH risk prediction with potential relevance for determining the optimal secondary prevention strategy, including the use of left atrial appendage occlusion. Following ICH, recommencing antiplatelets is probably safe in most patients, while the inconclusive results of recent randomized controlled trials of anticoagulant use makes recruitment to ongoing trials (including those testing left atrial appendage occlusion) in this area a high priority. Concern regarding CSVD and ICH risk after hyperacute stroke treatment appears to be unjustified in most patients, though some uncertainty remains regarding patients with very high CMB burden and other risk factors for ICH. We encourage careful phenotyping for underlying CSVD in future trials, with the potential to enhance precision medicine in stroke.