1. Dr.Bipin Bhimani
M.D.,D.M.
Consultant Neurophysician
Well care Hospital
Rajkot

2. Case :
• M / 44 yrs
• Sudden onset of
Weakness/ Clumsiness/ giving away of both LLS
• About to fall but was supported
• Lasted for few minutes (2-5 minutes)
• ? Sensory ( numbness)
• Recovered totally.

3. • RHD/MS/BMV done 1 month ago
• No AF/ clot/ LA-near ok / no smoke
• Past h/o ? Cerebellar Stroke 2 yrs back
(Admitted/No reports available)
• Ecospirin OD/150mg

13. • ? Spinal cord TIA
• ? Cerebral TIA
• ? Symptomatic microbleed

14. • Normal course:
admission, observation
Repeat ECHO
heparinisation
anticoagulants
• Any change in view of multiple micro bleeds ?

15. Affects many therapeutical
decisions
• Aspirin
• Clopidogrel
• Asp +Dypiridamole
• Asp+ Clop
• Asp+Clop+cilastazol
• Anticoagulants /Heparin
• tPA

16. CMBs/BMBs
• Mid 1990s
• Focal hemosiderin,DOHb,Ferittin
(macrophage)of previous hemorrhage
• ( perivascular)
• < 5 mm round (actually smaller)
• Usually BG/ SC , in CAA cortical
• Also cerelellum, brain stem
• Persists for many years

17. • Fibrohyalinosis or CAA, <200 micrometer
vessel rupture
• Gradient Echo ( focal areas of signal loss) T2
• Susptibility Weighted –better

18. Cortical (CAA) Vs SC (HT)

19. Criteria of CMBs
• 1 Black lesions on T2*-weighted MRI
• 2 Round or ovoid lesions (rather than linear)
• 3 Blooming effect on T2*-weighted MRI*
• 4 Devoid of signal hyperintensity on T1- or T2
• 5 At least half the lesion surrounded by brain
parenchyma
• 6 Distinct from other potential mimics such as
iron or calcium deposits
• 7 Clinical history excluding traumatic DAI

20. CMBs are seen in
• Healthy adults
• Healthy elderly
• Lacunar and other ischemic strokes
• ICH
• Cerebral amyloid angiopathy
• CADASIL
• Some genetic collagen disease
• Alz disease
• Moyamoya disease

21. Associations
• Older age
• Asian
• Male
• HT ?DM
• Smoking
• White matter disease
• ICH
• Lacunes/Ischemic strokes
• Low cholestrol (?)

22. • 53 yrs ----3.1%
• 60 yrs ----6%
• HT –
• Male more
• Ischemic -34%
• Hemorrhagic-60%
• Alz-20%
• Much more in recurrent strokes

23. Benign or pathological
• Small vessel disease
• Further Stroke burden
• ( ischemic/hemorrhagic)
• More bleed size
• Increase Hemorrhagic transformation of
infarcts
• Executive dysfunction
• Cognitive decline
• Further future events in CAA
• New bleed accumulates over time

24. CMB detection
• Tesla (field strength)
• Echo time
• Flip angle
• Slice thickness

25. Scores:
• MARS- Microbleed Anatomical Rating Scale
• BOMBs- Brain Observer Micro Bleed Scale

26. DDs
• Micro hemorrhagic mets
• Calcium /iron ( symmetrical )
• Cerebral Cavernoma (rare, hereditary)
• Capillary telangiectasias
• Leptomeningial hemosiderosis
• Vascular flow voids (can trace vessel course)
• Diffuse Axonal injury ( trauma )

27. Prevention
• Anti HT ( peri/Indapa)
• Cessation of smoking
• Avoid anticoagulants

29. Is CMBs symptomatic?
• Acute –usually no symptoms ,occ seizure by
irritation of brain parencyma , occ focal
symptoms
• Chronic- executive dysfunction
• Not an innocent bystander

30. Suspected acute symptomatic
CMBs

31. paradox
• In some recurrent “TIA” like cases, incressing
dose of antiplatelets or adding new one
exacerbates problem…while reducing
antiplatelets or anti-convulsants solve the
problems!

32. CMBs and anti-thrombotics
• Should not be withheld
• Do not withheld aspirin
• Avoid double esp if multiple/Lobar CMBs

33. CMBs and anticoagulants
• Avoid anticoagulation or double anti platelets
in CAA ( multiple, lobar)

34. Warfarin ICH and CMBs

35. CMBs and tPA
• MR is usually not done
• Go ahead
• Minor Contraindication
• Statistically insignificant trend of increase ICH
• Symptomatic ICH rare

36. Thank you