Recurrent hemorrhages, new data, new decisions

Abstract

The incidence and prevalence of spontaneous intracerebral haemorrhage (ICH) continues to increase worldwide. ICH is associated with high mortality (1 year and 5 year survival estimated at 46% and 29% respectively), and data on subsequent stroke events in ICH survivors are limited. This leads to management dilemmas in patients who are at risk of ischaemic vascular events (involving the brain, heart or peripheral vasculature) or thromboembolic disease, and who may benefit from treatment with antiplatelet or anticoagulant medications. Assessment of the prognosis for these serious vascular events is crucial to make informed management decisions after ICH. Features which may help identify a higher risk of subsequent stroke events include: ICH location (lobar ICH, which, in some cases, is associated with cerebral amyloid angiopathy [CAA]) has a higher recurrent ICH rate, while deep ICH, associated with hypertensive arteriopathy has a lower recurrent ICH risk. Imaging biomarkers of cerebral small vessel disease including cerebral microbleeds, cortical superficial siderosis (which might also reflect the balance of CAA and hypertensive arteriopathy) also affect prognosis after ICH. Based on these data it has been suggested that, given their increased ICH risk, patients with lobar ICH or high-risk imaging biomarkers should not be offered antithrombotic therapy, even those with AF (which confers a particular high ischaemic stroke risk). However, some recent observational and randomised trial data challenge this assumption. This talk will review relevant data to guide the use of baseline ICH features can help assess prognosis to inform difficult clinical treatment decisions after ICH.