A Quandary on Blood Drops in the Brain
On Dec. 18, 2005, Ariel Sharon, then Israel’s prime minister, was
taken to a Jerusalem hospital with symptoms of a stroke, unable to
speak or understand what others were saying.

Nir Elias/Reuters
Ariel Sharon in 2002. Microbleeds were later detected in his brain.
Over the next 36 hours, his doctors found themselves in a quandary.
Mr. Sharon had two conditions that might lead to a new and devastating
stroke. And treating one condition could make the other one worse.

First, he was susceptible to blood clots that could be swept from his
heart to his brain, causing a major stroke. Anticlotting drugs might
protect him.

But his brain scans showed microbleeds, pinpoint drops of blood that
leaked from blood vessels in the brain. The fear was that an
anticlotting drug might turn a new microbleed into a life-threatening,
incapacitating hemorrhagic stroke.

Until recently, microbleeds were all but unknown. Now, with improved
scans, they are turning up constantly; one recent study found them in
the brains of 1 out of 5 people age 60 and older. And they are leading
to a classic conundrum of modern medicine: Just because something
turns up on an M.R.I. scan, is it significant? And if it may or may
not be significant, what to do about it?

With strokes, the stakes can be life or death. Or, as happened with
Mr. Sharon, somewhere in between.

His doctors decided that blood clots were his biggest risk, so they
gave him heparin, an anticlotting drug. Two weeks later, he had a
major bleeding stroke. Mr. Sharon remains in a persistent vegetative
state to this day, awake but not aware, unable to respond, unable to
communicate, able to breathe but unable to think.

It can never be proved that an anticlotting drug caused a stroke in an
individual case. But it is known that when patients taking such drugs
have hemorrhagic strokes, the strokes are much worse, with double the
normal fatality rate.

The microbleed story began when neurologists, using newer magnetic
resonance imaging techniques, began seeing them in patients who had
symptoms of a stroke or, in some cases, signs of an electrical
disturbance in the brain. A patient might have numbness or tingling in
part of the face that then migrated to a hand and went away.

On scans, neurologists would see a few drops of blood in the patient’s
brain, smaller than the tip of a pen. Or they would see tiny drops in
routine scans in patients with dementia, or in patients who had had a
serious stroke.

Now, neurologists are seeing microbleeds even in some patients who
seemed free of neurological problems — people who were given a scan
because of a blow to the head, or memory problems, or headaches.

“They clearly are being picked up more often,” said Dr. Steven M.
Greenberg, a neurologist at Massachusetts General Hospital who studies
microbleeds. “That’s one reason why we all get nervous about getting
scans on people who don’t necessarily need them. You have to be able
to deal with the consequences.”

With microbleeds, that can be difficult. At a loss as to what to do,
doctors call specialists like Dr. Greenberg, asking for advice.

“I get a lot of calls I didn’t used to get,” Dr. Greenberg says. “And
they mostly involve questions I can’t answer.”

When the bleeds are on the outer surface of the brain, they often seem
associated with a condition in which blood vessels are damaged by the
protein amyloid. This is the same protein that piles up in the brains
of patients with Alzheimer’s disease; microbleeds from amyloid can be
associated with dementia.

Other times, the microbleeds are deep in the brain and may be linked
to high blood pressure, a leading cause of strokes. But it is not
clear whether microbleeds, especially those deep in the brain, are of
any real consequence. Until recently, no one asked how often they turn
up in healthy people, nor whether they predict strokes or other
serious brain damage.

That changed when Dr. Monique M. B. Breteler, a neuroepidemiologist at
Erasmus University in Rotterdam, the Netherlands, decided to look for
microbleeds among residents of her city.

“If there were more than we knew of in the general population, that
might — and I want to stress might — have important consequences,” Dr.
Breteler said. “That is why we started to look for them.”

For more than a decade, Dr. Breteler and her colleagues have followed
a group of Rotterdam residents age 45 and older. The goal is to do
repeated brain scans on 8,000 people; so far they have scanned nearly
4,000 and are analyzing those data.

“What we found came as a big surprise,” Dr. Breteler said. Previous
estimates were that 5 to 7 percent of healthy older people had
microbleeds. The Rotterdam study found them in more than 20 percent.
And the older the person, the more likely the microbleeds. They were
present in 18 percent of 60-year-olds and nearly 40 percent of those
over 80.

“We now know that these changes are there and that they are frequent,”
Dr. Breteler said. “But we don’t know yet what their clinical impact
is, what their prognosis is.”

Still, she and other experts say, there is reason for concern.

Dr. Greenberg has found that if the microbleed is near the brain’s
surface, where it might be associated with amyloid, then anticlotting
drugs are more likely to precipitate a brain hemorrhage. But sometimes
a patient is at such grave risk of a stroke that the balance tips in
favor of an anticlotting drug anyway, he says.

If the microbleed is deep in the brain, it is not clear whether
anticlotting drugs are dangerous.

Even patients who come in with symptoms that might be caused by
microbleeds can pose a problem.

Edward Reynolds, 74, of Beverly, Mass., was referred to Dr. Greenberg
after an episode in which part of his face went numb, then his hand,
and then the numbness faded and he felt fine. He had an abnormal heart
rhythm, which meant that anticlotting drugs might help him avoid a
stroke caused by blood clots in his heart.

But an M.R.I. scan found microbleeds on the surface of his brain,
which meant they were probably associated with amyloid. And that meant
powerful anticlotting drugs like warfarin could be dangerous for him.

“Here’s a guy on a knife edge of being anticoagulated or not,” Dr.
Greenberg said. “There really are major risks on both sides. You can
see bad things happening either way.”

Dr. Greenberg decided in the end that the risk from drug like warfarin
was not justified. He advised Mr. Reynolds to take baby aspirin, with
its mild anticlotting properties.

“It’s only one decision, but it’s a big one,” Dr. Greenberg said.

So far, Mr. Reynolds has done well, with no recurrence of the numbness
and no signs of a stroke.

“I’m feeling pretty good,” he said.

Who loves ya.
Tom

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