Should Patients With Ischemic Stroke or Transient Ischemic Attack With Atrial Fibrillation and Microbleeds Be Anticoagulated?

  title={Should Patients With Ischemic Stroke or Transient Ischemic Attack With Atrial Fibrillation and Microbleeds Be Anticoagulated?},
  author={Ashkan Shoamanesh and Andreas Charidimou and Mukul Sharma and Robert G. Hart},
The risk of atrial fibrillation-associated ischemic stroke can be significantly mitigated by anticoagulant therapy with a proven 67% relative risk reduction in ischemic stroke compared with no antithrombotic use.1 Despite this significant therapeutic effect, there still exists substantial underuse of anticoagulants.2 This underuse is driven by exaggerated concerns for anticoagulant-related bleeding complications and in particular, hemorrhagic stroke.3 This concern is further amplified in… 
Microbleeds and Outcome in Patients With Acute Ischemic Stroke and Atrial Fibrillation Taking Anticoagulants
The study results indicate that the risk of future MACCE increased with increasing CMB burden in patients with AIS and atrial fibrillation taking OACs, while the anatomic location of CMBs did not influence therisk of futureMACCE.
Oral Anticoagulation in Asian Patients With Atrial Fibrillation and a History of Intracranial Hemorrhage
NOAC might be a more effective and safer treatment option for Asian patients with nonvalvular AF and a prior history of ICH, and was associated with a significant lower risk of I CH and ischemic stroke compared with warfarin.
Risk of intracerebral haemorrhage in Chinese patients with atrial fibrillation on warfarin with cerebral microbleeds: the IPAAC-Warfarin study
In Chinese patients with AF on warfarin, presence of multiple CMBs may be associated with higher rate of ICH than ischaemic stroke, and larger studies through international collaboration are needed to determine the risk:benefit ratio of oral anticoagulants in patients withAF of different ethnic origins.
Antiplatelet Therapy in Cerebral Small Vessel Disease
Current data does not support withholding antiplatelet therapy where otherwise indicated in patients with cerebral microbleeds on MRI or those who have suffered intracerebral hemorrhage, andAntiplatelet monotherapy appears to provide persistent secondary stroke prevention in patientswith lacunar stroke.
Microbleeds and the Effect of Anticoagulation in Patients With Embolic Stroke of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Randomized Clinical Trial.
Microbleeds mark an increased risk of recurrent stroke, ischemic stroke, and all-cause mortality in patients with a history of stroke and microbleeds on magnetic resonance imaging in the NAVIGATE ESUS trial.
Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment
A review of the results of recent randomized clinical trials that build upon information gleaned from prior studies on the potential benefit of combined antiplatelet and anticoagulant therapy for stroke prevention.
Are lobar microbleeds of diagnostic value in the community?
Whether strictly lobar CMBs have the same diagnostic accuracy for CAA in the general population remains uncertain, and their value in this setting has come into question following disappointing positive and negative predictive values for probable CAA reported.
Predictors of neurologists confirming or overturning emergency physicians' diagnosis of TIA or stroke.
Physicians should have a high index of suspicion of cerebral ischemia in patients with advanced age, smoking history, language disturbance, or infarcts on CT, including those with isolated vertigo, syncope, or bilateral symptoms.
Clinical perspectives on ischemic stroke
Cerebral amyloid angiopathy: diagnosis and potential therapies
A literature search was conducted using MEDLINE on the topics of imaging, biomarkers, ICH prevention and treatment trials in CAA, focusing on its current diagnosis and management and opportunities for future therapeutic approaches.


Embolic Stroke, Atrial Fibrillation, and Microbleeds: Is There a Role for Anticoagulation?
A 73-year-old man presents with an ischemic stroke. Work-up reveals paroxysmal atrial fibrillation (AF), and magnetic resonance imaging (MRI) shows a small cortical infarct and 8 incidental cortical
The Clinical Relevance of Microbleeds in Stroke study (CROMIS-2): rationale, design, and methods
It is hypothesized that cerebral microbleeds and other markers of cerebral small vessel disease on magnetic resonance imaging, and genetic polymorphisms are associated with an increased risk of oral anticoagulant-associated intracerebral hemorrhage, with potential to improve risk prediction.
MRI Screening for Chronic Anticoagulation in Atrial Fibrillation
MRI screening appears most appropriate for a subset of atrial fibrillation patients, such as those with intermediate stroke risk, and may provide reassurance for clinicians whose concerns for ICH tend to outweigh benefits of anticoagulation.
The clinical relevance of cerebral microbleeds in patients with cerebral ischemia and atrial fibrillation
Further study is warranted to assess larger numbers of patients to determine appropriate antithrombotic use in this high-risk population and determine the future risk of intracerebral hemorrhage and cerebral infarction.
Outcomes With Edoxaban Versus Warfarin in Patients With Previous Cerebrovascular Events: Findings From ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48)
HDER is at least as effective and is safer than warfarin, regardless of the presence or the absence of previous IS or TIA, and annualized intracranial hemorrhage rates were lower with HDER than with warfar in this prespecified subgroup analysis.
Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation
An updated meta-analysis of all currently available randomized trials that extends observations about the efficacy and safety of antithrombotic therapies for preventing stroke in patients who have atrial fibrillation is presented.
Recurrent stroke risk and cerebral microbleed burden in ischemic stroke and TIA
CMBs are associated with increased stroke risk after IS or TIA, with increasing CMB burden (compared to no CMBs), the risk of ICH increases more steeply than that of IS.