Article Commentary: “Association of Enlarged Perivascular Spaces and Anticoagulant-Related Intracranial Hemorrhage”
Song J. Kim, MD
Best JG, Barbato C, Ambler G, Du H, Banerjee G, Wilson D, Shakeshaft C, Cohen H, Yousry TA, Al-Shahi Salman R, et al. Association of enlarged perivascular spaces and anticoagulant-related intracranial hemorrhage. Neurology. 2020;95:e2192-e2199.
The clinical significance of cortical superficial siderosis, cortical microbleeds, and cortical subarachnoid hemorrhages — imaging markers of cerebral amyloid angiopathy (CAA) — has become clearer over the years as representing future and recurrent risk of symptomatic intracranial hemorrhages (sICH), especially lobar bleeds. Recently, enlarged perivascular spaces (EPVS) in the basal ganglia (BG-EPVS) and the centrum semiovale (CS-EPVS) have also come to the attention of researchers as possibly linked to hypertensive arteriopathy and CAA, respectively. Given this, could EPVS carry a risk of symptomatic intracranial hemorrhage (sICH) in patients starting anticoagulation?
To answer this question, Best et al. conducted a post-hoc analysis of the CROMIS-2 (AF) study, a multicenter prospective cohort study examining the relationship between cerebral microbleeds and anticoagulant-related sICH over a 2-year follow-up period. Using baseline MRI imaging pre-anticoagulation, the number of BG-EPVS and CS-EPVS were enumerated and dichotomized (greater than 10 or less than 10). The association of EPVS with symptomatic intracranial hemorrhage was then investigated using Cox Regression analysis, which also incorporated other variables such as cortical microbleeds and lacunes.