Reader Response: Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin
George KVilanilam, Clinical Neurology Fellow, Mayo Clinic
NeethuGopal, Research Trainee, Mayo Clinic
AnjaliAgarwal, Research Trainee, Mayo Clinic
Mohammed K.Badi, Research Trainee, Mayo Clinic
Submitted August 18, 2018
We read with interest the study by Lehtola et al. [1] Anticoagulation (AC) in atrial fibrillation (AF) reduces the risk of ischemic stroke, but at the cost of increasing the risk of hemorrhagic stroke.
We feel that the burden of cerebral microbleeds (CMBs) might provide additional information as to the true risk of spontaneous intracranial hemorrhage (ICH) in the study population. CMBs are a logical marker for ICH risk in patients with AF. An adjusted pooled analysis performed by the META-MICROBLEEDS study group showed that CMBs conferred a 3-fold increase in the risk of ICH in patients with AF. [2] Moreover, it has also been suggested that warfarin is independently associated with the development of new CMBs. [3] As males and the elderly population have a higher prevalence of CMBs, it is hard to ignore the higher mean age (78) and the higher proportion of males (58%) in this study [1] suggesting a possible 'triple' interaction among AF, CMB, and warfarin raising the overall risk of ICH.
Systematic studies in identifying patients at high risk of hemorrhagic stroke in the setting of AF and AC might open doors for physicians to preferentially reduce the risk of ischemic stroke by other means.
1. Lehtola H, Palomäki A, Mustonen P, et al. Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin. Neurol Clin Pract 2018;8:311-317.
2. Charidimou A, Karayiannis C, Song TJ, et al. Brain microbleeds, anticoagulation, and hemorrhage risk: Meta-analysis in stroke patients with AF. Neurology 2017;89:2317-2326.
3. Soo YO, Yang SR, Lam WW, et al. Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds. J Neurol 2008;255:1679-1686.
For disclosures, please contact the editorial office at [email protected].
We read with interest the study by Lehtola et al. [1] Anticoagulation (AC) in atrial fibrillation (AF) reduces the risk of ischemic stroke, but at the cost of increasing the risk of hemorrhagic stroke.
We feel that the burden of cerebral microbleeds (CMBs) might provide additional information as to the true risk of spontaneous intracranial hemorrhage (ICH) in the study population. CMBs are a logical marker for ICH risk in patients with AF. An adjusted pooled analysis performed by the META-MICROBLEEDS study group showed that CMBs conferred a 3-fold increase in the risk of ICH in patients with AF. [2] Moreover, it has also been suggested that warfarin is independently associated with the development of new CMBs. [3] As males and the elderly population have a higher prevalence of CMBs, it is hard to ignore the higher mean age (78) and the higher proportion of males (58%) in this study [1] suggesting a possible 'triple' interaction among AF, CMB, and warfarin raising the overall risk of ICH.
Systematic studies in identifying patients at high risk of hemorrhagic stroke in the setting of AF and AC might open doors for physicians to preferentially reduce the risk of ischemic stroke by other means.
1. Lehtola H, Palomäki A, Mustonen P, et al. Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin. Neurol Clin Pract 2018;8:311-317.
2. Charidimou A, Karayiannis C, Song TJ, et al. Brain microbleeds, anticoagulation, and hemorrhage risk: Meta-analysis in stroke patients with AF. Neurology 2017;89:2317-2326.
3. Soo YO, Yang SR, Lam WW, et al. Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds. J Neurol 2008;255:1679-1686.
For disclosures, please contact the editorial office at [email protected].