Use of MRI for Risk Stratification in Anticoagulation Decision Making in Atrial Fibrillation: Promising, but More Data are Needed for a Robust Algorithm

We read with interest Mark Fisher’s review paper highlighting the very difficult decision-making many stroke physicians and neurologists are facing around the world on chronic anticoagulation for atrial fibrillation (AF) (1). As the author points out, oral anticoagulants are underutilized, often based on erroneous clinical reasoning, which may over-estimate bleeding risks. Part of the problem is that current clinical scoring systems for bleeding risk (e.g., HEMORR2HAGES, ATRIA, and HAS-BLED) might be of limited value in everyday clinical practice, especially in regard to intracerebral hemorrhage (ICH), the most feared and devastating complication of anticoagulation (2). The development of advanced brain MR imaging provides unique promise to tailor individual treatment decisions on anticoagulation by better balancing ICH and ischemic stroke risks (2). New radiological markers of cerebral small vessel disease (including cerebral microbleeds, cortical superficial siderosis, and white matter changes, etc.) have the potential to provide information about the presence of a hemorrhage-prone microangiopathy, which seems to underlie anticoagulation-related ICH (3–5).