Answer
Patients with cerebral amyloid angiopathy (CAA) have an increased risk of bleeding while taking warfarin, even when the level of anticoagulation is in the therapeutic range (ie, international normalized ratio, 2-3). The vasculopathic changes may predispose these patients to small bleeds. The use of anticoagulants may result in the enlargement of small hemorrhages that otherwise would have remained asymptomatic.
Withdrawal of anticoagulant agents is a prudent intervention to prevent recurrences in patients with prior lobar hemorrhages, particularly if GRE MRI suggests earlier petechial hemorrhages. Antiplatelet agents are a safer alternative.
Strong evidence regarding the relationship between CAA and antithrombotic therapy is lacking. Data suggested that GRE microbleeds were more prevalent among a cohort of aspirin users in the Rotterdam Scan Study; however, more research is needed to understand the dynamic between antithrombotic therapy and the risk of intracerebral hemorrhage and microbleed formation. [19]
In the patient with coronary artery disease, cardiac stents, and/or ischemic stroke, the benefit of antithrombotic therapy is clear and withdrawal of antiplatelet therapy requires prudent consideration of multiple factors. Management must be tailored to each individual case, taking into account the risk of hemorrhage, the benefit of stroke prophylaxis, and the preferences of the patient.
Two studies support the treatment of hypertension to prevent hemorrhage recurrence in CAA. The first, an analysis of patients in the PROGRESS trial, showed that those on active therapy with perindopril had fewer recurrences of all types of hemorrhage than those in the control group. [16] A second study, a single center cohort study of patients with lobar and nonlobar hemorrhages, suggested that inadequate blood pressure control during follow-up was associated with higher risk of lobar as well as nonlobar ICH recurrence. [20]
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MRI Brain GRE 3.0 TeslaTop: Multiple scattered microbleeds in multiple vascular territories in patient with hyperhomocysteinemia and methylene-tetrahydrofolate reductase mutation. Middle: Acute parenchymal hematoma with typical appearance of right occipital microbleed and left parietal chronic microhemorrhage.Bottom: Microbleeds involving multiple lobes. Chronic hemorrhage in the left parietal lobe with typical slit-like appearance.
