Management of Cerebral Microbleeds in Clinical Practice


Cerebral microbleeds (CMBs) are very frequent diagnoses with MRI imaging in the elderly or in patients with cerebral infarction, intracranial hemorrhage (ICH), and dementia. The mechanisms for CMBs are not fully understood but may be secondary to injury to the vascular wall from long-standing hypertension or amyloid deposition in the tissue. The presence of CMB increases the risk for stroke, dementia, and death. The increasing number of CMBs is also associated with a higher risk of hemorrhagic complications with the long-term use of anticoagulants in atrial fibrillation and in patients requiring thrombolysis for acute stroke. The presence of CMBs is however not a contraindication for anticoagulation or thrombolysis as was recently shown from the results of the CROMIS-2 study. This review will summarize our current understanding of the natural history of CMBs and offer suggestions on the best management in common clinical settings.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Vernooij MW, van der Lugt A, Ikram MA, Wielopolski PA, Niessen WJ, Hofman A, et al. Prevalence and risk factors of cerebral microbleeds the Rotterdam Scan Study. Neurology. 2008;70:1208–14.

    Article  CAS  PubMed  Google Scholar 

  2. 2.

    Greenberg SM, Vernooij MW, Cordonnier C, Viswanathan A, al-Shahi Salman R, Warach S, et al. Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol. 2009;8:165–74.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Charidimou A, Blacker D, Viswanathan A. Context is everything: from cardiovascular disease to cerebral micr0obleeds. Int J Stroke. 2018;13:6–10.

    Article  PubMed  Google Scholar 

  4. 4.

    Ding J, Sigurðsson S, Jónsson PV, Eiriksdottir G, Meirelles O, Kjartansson O, et al. Space and location of cerebral microbleeds, cognitive decline, and dementia in the community. Neurology. 2017;88:2089–7.

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Scharf J, Bräuherr E, Forsting M, Sartor K. Significance of haemorrhagic lacunes on MRI in patients with hypertensive cerebrovascular disease and intracerebral haemorrhage. Neuroradiology. 1994;36:504–8.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Daugherty AM, Raz M. Incident risk and progression of cerebral microbleeds in healthy adults: a multi-occasion longitudinal study. AJNR. 2017;38:2251–6.

    Article  Google Scholar 

  7. 7.

    Cordonnier C, Al-Shahi Salman R, Wardlaw J. Spontaneous brain microbleeds: systematic review, subgroup analyses and standards for study design and reporting. Brain. 2007;130:1988–2003.

    Article  PubMed  Google Scholar 

  8. 8.

    Kwa VI, Franke CL, Verbeeten B, Stam J. Amsterdam Vascular Medicine Group. Silent intracerebral microhemorrhages in patients with ischemic stroke. Ann Neurol. 1998;44:372–7.

    Article  CAS  PubMed  Google Scholar 

  9. 9.

    Poels MM, Ikram MA, van der Lugt A, et al. Incidence of cerebral microbleeds in the general population. Stroke. 2011;42:656–61.

    Article  PubMed  Google Scholar 

  10. 10.

    Jeon SB, Kwon SU, Cho AH, Yun SC, Kim JS, Kang DW. Rapid appearance of new cerebral microbleeds after acute ischemic stroke. Neurology. 2009;73:1638–44.

    Article  PubMed  Google Scholar 

  11. 11.

    Mackey J, Wing JJ, Norato G, Sobotka I, Menon RS, Burgess RE, et al. High rate of microbleed formation following primary intracerebral hemorrhage. Int J Stroke. 2015;10:1187–91.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Saito T, Kawamura Y, Sato, et al. Cerebral microbleeds remain for nine years: a prospective study with yearly magnetic resonance imaging. J Stroke Cerebrovasc Dis. 2018;27:315–32.

    Article  PubMed  Google Scholar 

  13. 13.

    Fisher M. Cerebral microbleeds and thrombolysis: clinical consequences and mechanistic implications. JAMA Neurol. 2016;73:632–5.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Janaway BM, Simpson JE, Hoggardt N, et al. Brain hemosiderin in older people: pathological evidence for ischemic origin of MRI microbleeds. Neuropathol Appl Neurobiol. 2014;40:258–69.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Haller S, Montandon ML, Lazeyras F, Scheffler M, Meckel S, Herrmann FR, et al. Radiologic-histopathologic correlation of cerebral microbleeds using pre-mortem and post-mortem MRI. PLoS One. 2016;11:e0167743.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Pasi M, Charidimou A, Boulouis G, Auriel E, Ayres A, Schwab KM, et al. Mixed-location of cerebral hemorrhage/microbleeds: underlying microangiopathy and recurrence risk. Neurology. 2018;90:e119–26.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Han BH, Zhou ML, Johnson AW, Singh I, Liao F, Vellimana AK, et al. Contribution of reactive oxygen species to cerebral amyloid angiopathy, vasomotor dysfunction, and microhemorrhage in aged Tg2576 mice. Proc Natl Acad Sci. 2015;112:E881–90.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Kövari E, Charidimou A, Herrmann FR, Giannakopoulos P, Bouras C, Gold G. No neuropathological evidence for a direct topographical relation between microbleeds and cerebral amyloid angiopathy. Acta Neuropathol Commun. 2015;3:49.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Gregoire SM, Charidimou A, Gadapa N, Dolan E, Antoun N, Peeters A, et al. Acute ischaemic brain lesions in intracerebral haemorrhage: multicentre cross-sectional magnetic resonance imaging study. Brain. 2011;134:2376–86.

    Article  PubMed  Google Scholar 

  20. 20.

    Pasi M, Boulouis G, Fotiadis P, Auriel E, Charidimou A, Haley K, et al. Distribution of lacunes in cerebral amyloid angiopathy and hypertensive small vessel disease. Neurology. 2017;88:2162–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Van Veluw SJ, Biessels GJ, Klijn CJ, Rozemuller AJ. Heterogeneous histopathology of cortical microbleeds in cerebral amyloid angiopathy. Neurology. 2016;86:867–71.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Akoudad S, Portegies ML, Koudstaal PJ, Hofman A, van der Lugt A, Ikram MA, et al. Cerebral microbleeds are associated with an increased risk of stroke. Circulation. 2015;132:509–16.

    Article  PubMed  Google Scholar 

  23. 23.

    Chen W, Zhu W, Kovanlikaya I, Kovanlikaya A, Liu T, Wang S, et al. Intracranial calcifications and hemorrhages: characterization with quantitative susceptibility imaging. Radiology. 2014;270:496–506.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Charidimou A, Kakar P, Fox Z, Werring DJ. Cerebral microbleeds and recurrent stroke risk. Stroke. 2013;44:995–1001.

    Article  PubMed  Google Scholar 

  25. 25.

    Lim JS, Hong KS, Kim GM, Bang OY, Bae HJ, Kwon HM, et al. Cerebral microbleeds and early recurrent stroke after transient ischemic attack: results from the Korean Transient Ischemic Attack Expression Registry. JAMA Neurol. 2015;72:301–8.

    Article  PubMed  Google Scholar 

  26. 26.

    Lee SH, Kim BJ, Roh JK. Silent microbleeds are associated with volume of primary intracerebral hemorrhage. Neurology. 2006;66:430–2.

    Article  PubMed  Google Scholar 

  27. 27.

    Charidimou A, Shams S, Romero JR, Ding J, Veltkamp R, Horstmann S, et al. Clinical significance of cerebral microbleeds on MRI: a comprehensive meta-analysis of ICH, ischemic stroke, mortality and dementia in cohort studies. Int J Stroke. 2018 (in press);13:454–68.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Smith EE, Saposnik G, Biessels GJ, Doubal FN, Fornage M, Gorelick PB, et al. Prevention of stroke in patients with silent cerebrovascular disease. Stroke. 2017;48:e44–71.

    PubMed  Google Scholar 

  29. 29.

    Song TJ, Kim J, Song D, Nam HS, Kim YD, Lee HS, et al. Association of cerebral microbleeds with mortality in stroke patients having atrial fibrillation. Neurology. 2014;83:1308–15.

    Article  PubMed  Google Scholar 

  30. 30.

    Lovelock CE, Cordonnier C, Naka H, al-Shahi Salman R, Sudlow CLM, The Edinburgh Stroke Study Group, et al. Antithrombotic drug use, cerebral microbleeds, and intracerebral hemorrhage. Stroke. 2010;41:1222–8.

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Vernooij MW, Haag MD, van der Lugt A, Hofman A, Krestin GP, Stricker BH, et al. Use of antithrombotic drugs and the presence of cerebral microbleeds: the Rotterdam Scan Study. Arch Neurol. 2009;66:714–20.

    Article  PubMed  Google Scholar 

  32. 32.

    Horstmann S, Möhlenbruch M, Wegele C, Rizos T, Laible M, Rauch G, et al. Prevalence of atrial fibrillation and association of previous antithrombotic treatment in patients with cerebral microbleeds. Eur J Neurol. 2015;22:1355–62.

    Article  CAS  PubMed  Google Scholar 

  33. 33.

    Lee SH, Ryu WS, Roh JK. Cerebral microbleeds are a risk factor for warfarin-related intracerebral hemorrhage. Neurology. 2009;72:171–6.

    Article  CAS  PubMed  Google Scholar 

  34. 34.

    Akoudad S, Darweesh SK, Leening MJ, et al. Use of coumarin anticoagulants and cerebral microbleeds in the general population. Stroke. 2014;45:3436–9.

    Article  CAS  PubMed  Google Scholar 

  35. 35.

    Ueno H, Naka H, Ohshita T, Kondo K, Nomura E, Ohtsuki T, et al. Association between cerebral microbleeds on T2*-weighted MR images and recurrent hemorrhagic stroke in patients treated with warfarin following ischemic stroke. Am J Neuroradiol. 2008;29:1483–6.

    Article  CAS  PubMed  Google Scholar 

  36. 36.

    Wilson D, Amber G, Shakeshaft C, et al. Cerebral microbleeds and intracranial hemorrhage risk in patients anticoagulated for atrial fibrillation after ischemic stroke or transient ischemic attacks (CROMIS-2): a multicentre observational cohort study. Lancet Neurol. 2018;2017:539–47.

    Article  Google Scholar 

  37. 37.

    Cordonnier C. Incident cerebral microbleeds in a cohort of intracerebral hemorrhage. Stroke. 2016;47:689–4.

    Article  CAS  PubMed  Google Scholar 

  38. 38.

    Tsivgoulis G, Zand R, Katsanos AH, Turc G, Nolte CH, Jung S, et al. Risk of symptomatic intracerebral hemorrhage after intravenous thrombolysis in patients with acute ischemic stroke and high cerebral microbleed burden: a meta-analysis. JAMA Neurol. 2016;73:675–83.

    Article  PubMed  Google Scholar 

  39. 39.

    O'donnell MJ, Eikelboom JW, Yusuf S, et al. Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study. Am Heart J. 2016;178:145–50.

    Article  CAS  PubMed  Google Scholar 

  40. 40.

    Chairidimou A, Shoamanesh A, Al-Shahi Salman R, et al. Cerebral amyloid anbgiopathy, cerebral microbleeds and implications for anticoagulation decisions: the need for a balanced approach. Int J Stroke. 2018;13:117–20.

    Article  Google Scholar 

  41. 41.

    Charidimou A, Shoamanesh A. Clinical relevance of microbleeds in acute stroke thrombolysis. Neurology. 2016;87:1534–41.

    Article  CAS  PubMed  Google Scholar 

  42. 42.

    Shoamanesh A, Kwok CS, Lim PA, Benavente OR. Postthrombolysis intracranial hemorrhage risk of cerebral microbleeds in acute stroke patients: a systematic review and meta-analysis. Int J Stroke. 2013;8:348–56.

    Article  PubMed  Google Scholar 

  43. 43.

    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke. 2018;49:e46–e110.

    Article  PubMed  Google Scholar 

  44. 44.

    Charidimou A, Turc G, Oppenheim C, Yan S, Scheitz JF, Erdur H, et al. Microbleeds, cerebral hemorrhage, and functional outcome after stroke thrombolysis. Stroke. 2017;48:2084–90.

    Article  PubMed  Google Scholar 

  45. 45.

    Shi ZS, Duckwiler GR, Jahan R, et al. New cerebral microbleeds after mechanical thrombectomy for large-vessel occlusion strokes. Medicine. 2015;94:e2180.

    Article  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Caldeira D, Gonçalves N, Ferreira JJ, Pinto FJ, Costa J. Tolerability and acceptability of non-vitamin K antagonist oral anticoagulants in atrial fibrillation: systematic review and meta-analysis. Am J Cardiovasc Drugs. 2015;15:259–65.

    Article  CAS  PubMed  Google Scholar 

  47. 47.

    Wang Z, Soo YO, Mok VC. Cerebral microbleeds. Stroke. 2014;45:2811–7.

    Article  PubMed  Google Scholar 

  48. 48.

    Wilson D, Jäger HR, Werring DJ. Anticoagulation for atrial fibrillation in patients with cerebral microbleeds. Curr Atheroscler Rep. 2015;17:1–5.

    Article  CAS  Google Scholar 

  49. 49.

    Shoamanesh A, Pearce LA, Bazan C, Catanese L, McClure LA, Sharma M, et al. Microbleeds in the SPS3 trial: stroke, mortality and treatment interactions. Ann Neurol. 2017;82:196–207.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Ungvari Z, Tarantini S, Kirkpatrick AC, Csiszar A, Prodan CI. Cerebral microhemorrhages: mechanisms, consequences, and prevention. Am J Phys Heart Circ Phys. 2017;312:H1128–43.

    Google Scholar 

  51. 51.

    Bosch J, Eikelboom JW, Connolly SJ, Bruns NC, Lanius V, Yuan F, et al. Rationale, design and baseline characteristics of participants in the Cardiovascular OutcoMes for People Using Anticoagulation StrategieS (COMPASS) trial. Can J Cardiol. 2017;33:1027–35.

    Article  PubMed  Google Scholar 

  52. 52.

    Ward SA, Raniga P, Ferris NJ, Woods RL, Storey E, Bailey MJ, et al. ASPREE-NEURO study protocol: a randomized controlled trial to determine the effect of low-dose aspirin on cerebral microbleeds, white matter hyperintensities, cognition, and stroke in the healthy elderly. Int J Stroke. 2017;12:108–13.

    Article  PubMed  Google Scholar 

  53. 53.

    Chatterjee S, Sardar P, Biondi-Zoccai G, Kumbhani D. New oral anticoagulants and the risk of intracranial hemorrhage. JAMA Neurol. 2013;70:1486–90.

    PubMed  Google Scholar 

Download references

Author information




All authors, i.e., Dr. Ashfaq Shuaib, Dr. Saadat Kamran, Dr. Naveed Akhtar, and Dr. Richard Camicioli contributed equally to the review article.

Corresponding author

Correspondence to Ashfaq Shuaib.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

For this type of study, formal consent is not required.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shuaib, A., Akhtar, N., Kamran, S. et al. Management of Cerebral Microbleeds in Clinical Practice. Transl. Stroke Res. 10, 449–457 (2019).

Download citation


  • Cerebral microbleeds
  • Stroke
  • MRI
  • Dementia