Boutitie Léa, Verny Marc, Alamowitch Sonia, Zerah Lorène
Département de gériatrie, Hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris Paris, France.
Département de gériatrie, Hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris Paris, France, Sorbonne Université, Team Neuronal Cell Biology and Pathology, UMR CNRS 8256, Paris, France.
Geriatr Psychol Neuropsychiatr Vieil. 2023 Mar 1;21(1):81-89. doi: 10.1684/pnv.2023.1076.
Cerebral amyloid angiopathy and atrial fibrillation are two frequent comorbidities in older patients, leading to a therapeutic dilemma on the risk-benefit ratio of long-term anticoagulation. These patients both have a risk of cardioembolic complications due to atrial fibrillation, and a risk of cerebral haemorrhage from cerebral amyloid angiopathy. Since there is no therapeutic consensus, the best therapeutic strategy should be discussed during a multidisciplinary staff, based on four risk estimations: 1) the baseline risk of intracerebral haemorrhage without anticoagulation; 2) the risk of ischaemic stroke without anticoagulation; 3) the expected increase of intracerebral haemorrhage with anticoagulation; 4) the expected reduction in ischaemic stroke risk with anticoagulation. The risk of intracerebral haemorrhage varies according to the cerebral amyloid angiopathy phenotype. Patients with transient neurological episode or cortical superficial siderosis have the highest risk of intracerebral haemorrhage. Direct oral anticoagulant should be preferred to vitamin K antagonists, as the risk of intracerebral haemorrhage is lower with direct oral anticoagulants. If anticoagulation is introduced, a close clinical and radiological monitoring should be performed every 6-12 months minimum. If it has been decided not to anticoagulate, left atrial appendage occlusion should be proposed. In all situations, close blood pressure control is essential to reduce the risk of intracerebral haemorrhage.
脑淀粉样血管病和心房颤动是老年患者中两种常见的合并症，这导致了长期抗凝治疗风险效益比方面的治疗困境。这些患者既因心房颤动有发生心源性栓塞并发症的风险，又因脑淀粉样血管病有发生脑出血的风险。由于没有治疗共识，最佳治疗策略应在多学科团队中基于四项风险评估进行讨论：1）未进行抗凝时脑出血的基线风险；2）未进行抗凝时缺血性卒中的风险；3）抗凝治疗时脑出血的预期增加风险；4）抗凝治疗时缺血性卒中风险的预期降低。脑出血风险因脑淀粉样血管病的表型而异。有短暂性神经发作或皮质浅表铁沉积症的患者脑出血风险最高。直接口服抗凝剂应优先于维生素K拮抗剂，因为直接口服抗凝剂导致脑出血的风险更低。如果开始抗凝治疗，至少应每6 - 12个月进行密切的临床和影像学监测。如果决定不进行抗凝治疗，则应建议进行左心耳封堵术。在所有情况下，严格控制血压对于降低脑出血风险至关重要。
