Do Cerebral Microbleeds Up the Risk for Bleeding After tPA?

Mark J. Alberts, MD


October 30, 2015

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Hello, and welcome to this Medscape stroke update. My name is Dr Mark Alberts, clinical vice-chair of neurology at UT Southwestern Medical Center in Dallas, Texas.

A very interesting study was published in the September 2015 issue of Neurology. Charidimou and colleagues[1] studied the association of cerebral microhemorrhages on MRI scan with symptomatic intracerebral hemorrhage in patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke.

The literature has tried to address this vexing issue for the past several years. This current meta-analysis looked at 10 studies including over 2000 patients. They found that the overall rate of symptomatic intracerebral hemorrhage was 5%, which is consistent with large studies looking at the rate of hemorrhage after treatment with intravenous (IV) tPA.

Cerebral microbleeds were found in 23% of patients. After tPA, 8.5% of patients with cerebral microbleeds had a symptomatic intracerebral hemorrhage vs about 4% without cerebral microbleeds. When baseline differences and other factors were controlled for, the odds ratio for intracerebral hemorrhage in patients with cerebral microbleeds vs without cerebral microbleeds was about 2.9.

The authors are not saying that folks with cerebral microbleeds should not be treated with IV tPA, and I agree with that approach. There is some selection bias, because patients had to be well enough to undergo an MRI. Typically, they would not have pacemakers and the like. Cerebral microbleeds may be a surrogate marker for significant underlying cerebral vascular disease, including hypertension, diabetes, and other perhaps poorly controlled risk factors.

It's important to know that when and if you do an MRI scan and you see cerebral microbleeds, these patients may be at somewhat higher risk for having an intracerebral hemorrhage. Again, it is not a reason to withhold tPA therapy. In late 2015, we do have other treatment options, including endovascular therapy, as we have talked about before. Out of all the therapies, IV tPA is the one that can be administered most rapidly and in the largest number of treatment venues.

Thank you all for joining me for this Medscape stroke update. Have a good day.


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