Treatment of acute ischemic stroke in patients with cerebral microbleeds: a decision analysis.
Treatment with anti-thrombotic agents reduces the likelihood of recurrent ischemic stroke. However, it may produce intracerebral hemorrhage. The risk of recurrence is highest shortly after an ischemic stroke has occurred irrespective of the ischemic stroke subtype. About one-fourth1 to one-half2 of the risk of recurrence at 1 year is accrued during the acute phase (first 2–4 weeks) of an ischemic stroke, and this risk declines further during the following 5 years.3 Similarly, the rates of intracerebral hemorrhage decline from 0.6% to 3% during the the first 2–4 weeks after an ischemic stroke4–13 to 0.16–0.23% annually thereafter.11,14

This time variance in complication rates indicates that the risk–benefit ratio of the treatment of patients with acute ischemic stroke may be different from that of their long-term care. Still, published analyses of the treatment of such patients have assumed that the risks of ischemic stroke recurrence and intracerebral hemorrhage are constant over the patient’s lifetime,15 or over the first year after ischemic stroke.16 Therefore, the conclusions of these analyses may not pertain to patients with acute ischemic stroke. The management of ischemic stroke in patients with cerebral microbleeds is particularly uncertain. About one-fourth of the patients with ischemic stroke have cerebral microbleeds that may predict a higher risk of intracerebral hemorrhages.17 Still, we know of no randomized studies comparing the risks and benefits of anti-thrombotic treatment in patients with and without cerebral microbleeds.

When clinical decisions must be made in the absence of evidence, an analysis of the benefits (efficacy) and risks (adverse effects) of alternative management options may identify the treatment of choice and the specific areas of uncertainty that should be explored by future research. In this article, we use a decision tree to compare no treatment, aspirin or anti-coagulation in …