Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, UK.
Int J Stroke. 2023 Jan;18(1):44-52. doi: 10.1177/17474930221106014. Epub 2022 Jun 24.
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.
平衡复发性缺血和抗血栓相关出血的风险，特别是颅内出血 (ICH)，是缺血性卒中和短暂性脑缺血发作二级预防的关键挑战。在超急性缺血性卒中中，急性再灌注治疗的使用取决于预期获益和 ICH 风险的平衡。脑小血管疾病 (CSVD) 导致大多数自发性 ICH。在这里，我们回顾了 CSVD 的神经影像学标志物与抗血栓和溶栓相关 ICH 之间的关联证据，重点是脑微出血 (CMB)。我们讨论了它们在 ICH 预测中的作用以及对临床决策的实际影响。尽管目前的观察性数据表明，CSVD 存在不应排除缺血性卒中和 TIA 患者的抗血栓治疗，但它们有助于提高 ICH 风险预测的准确性，可能对确定最佳二级预防策略具有潜在意义，包括使用左心耳封堵术。ICH 后，大多数患者可能再次使用抗血小板治疗是安全的，而抗凝剂使用的最近随机对照试验结果不确定，使得在该领域招募正在进行的试验（包括测试左心耳封堵术的试验）成为当务之急。对于大多数患者来说，对超急性卒中治疗后 CSVD 和 ICH 风险的担忧似乎是没有根据的，但对于 CMB 负荷非常高和 ICH 其他风险因素的患者，仍存在一些不确定性。我们鼓励在未来的试验中对潜在的 CSVD 进行仔细的表型分析，有可能增强卒中的精准医学。
