Enlarged perivascular spaces could indicate anticoagulant-related haemorrhage

Enlarged perivascular spaces  could indicate anticoagulant-related haemorrhage

Presence of enlarged perivascular spaces within the basal ganglia among patients taking oral anticoagulants may be a new risk factor for intracranial haemorrhage (ICH), according to a statistical analysis of the CROMIS-2 (AF) study. The findings are published in the journal Neurology.

Intracerebral haemorrhage is the most dangerous complication of oral anticoagulant treatment (OAT). Up to half of patients with OAT-related ICH experience early clinical deterioration due to active bleeding, leading to hematoma enlargement.

The researchers from the Stroke Research Center at the UCL Queen Square Institute of Neurology in London and colleagues examined the data from 1,386 patients with atrial fibrillation who had experienced a recent transient ischemic attack or ischemic stroke. All patients underwent MRI before starting oral anticoagulants.

The cross-sectional studies conducted in the ICH survivors during the study suggested that enlarged basal ganglia perivascular spaces (BGPVS) could indicate deep ICH, increased white matter hyperintensity volume, and deep cerebral microhemorrhages (CMBs). Similarly, enlarged centrum semiovale perivascular spaces (CSOPVS) could represent amyloid-beta pathology, including cerebral amyloid angiopathy (CAA) and lobar ICH, according to the researchers. As a result, PVS could also represent increased ICH risk.

“In cognitively-impaired patients, BGPVS is associated with hypertension, deep CMBs and lacunes, and CSOPVS with lobar CMBS, cortical superficial siderosis and Alzheimer’s disease,” the team noted.

During 3,251 participant years of follow-up (mean follow-up period, 2.34 years), 14 symptomatic ICHs occurred. Specifically, there were 11 intracerebral haemorrhages, two subdural haemorrhages and one subarachnoid haemorrhage. Median time from the start of anticoagulation therapy to symptomatic ICH was 272 days.

In univariable analysis, diabetes, the presence of CMBs, the presence of lacunes and more than 10 BGPVS correlated with symptomatic ICH, though CSOPVS did not. A multivariable model included all variables found to have significant associations on univariable analysis. In this model, more than 10 BGPVS (HR = 8.96) and diabetes (HR = 3.91) remained significant risk factors for symptomatic ICH.

The primary finding from the study is the association between enlarged PVS within the basal ganglia and oral anticoagulant-related intracranial haemorrhages, independent of major vascular risk factors and other markers of cerebral small vessel disease.

The statistics for this association are consistent with a clinically meaningful association pointing to the possibility that enlarged BGPVS represent a clinically relevant marker for oral anticoagulant-related ICH risk, the researchers wrote.