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Sun L, Zhou W, Ploen R, Zorn M, Veltkamp R. Anticoagulation with dabigatran does not increase secondary intracerebral haemorrhage after thrombolysis in experimental cerebral ischaemia. Thromb Haemost 2013; 110:153-61. [PMID: 23615682 DOI: 10.1160/th12-12-0942] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/21/2013] [Indexed: 01/12/2023]
Abstract
Dabigatran etexilate (DE) has recently been introduced for stroke prevention in atrial fibrillation, but management of acute ischaemic stroke during therapy with DE is a challenge. Thrombolysis is contraindicated because of a presumed increased risk of intracerebral haemorrhagic complications. We studied in different ischaemia models whether DE increases secondary haemorrhage after thrombolysis. C57BL/6 mice were anticoagulated with high-dose DE or warfarin. After 2 hour (h) or 3 h transient filament MCAO, rt-PA was injected. At 24 h after MCAO, secondary haemorrhage was quantified using a macroscopic haemorrhage score and haemoglobin spectrophotometry. Post-ischaemic blood-brain-barrier (BBB) damage was assessed using Evans blue. To increase the validity of findings, the duration of anticoagulation was prolonged in mice (5 x DE over 2 days), and the effect of DE after thrombolysis was also examined in thromboembolic MCAO in rats.Pretreatment with warfarin resulted in significantly more secondary haemorrhage (mean haemorrhage score 2.6 ± 0.2) compared to non-anticoagulated animals (1.7 ± 0.3) and DE (9 mg/kg, 1.6 ± 0.3) in 2 h ischaemia. Also after a 3 h period of ischaemia, haemorrhage was more severe in animals anticoagulated with warfarin compared to 9 mg/kg DE and non-anticoagulated control. Prolonged or enteral dabigatran pretreatment led to identical results. Also, thrombolysis after thromboembolic MCAO in rats did not induce more severe bleeding in DE-treated animals. Mice pretreated with warfarin had higher BBB permeability and increased activation of matrix-metalloproteinase 9. In conclusion, DE does not increase the risk of secondary haemorrhage after thrombolysis in various rodent models of ischaemia and reperfusion. The implications of this finding for stroke patients have to be determined in the clinical setting.
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Affiliation(s)
- Li Sun
- Department of Neurology, Ruprecht-Karls-University Heidelberg, INF 400, 69120 Heidelberg, Germany
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102
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Are blood stream infections associated with an increased risk of hemorrhagic stroke in patients with a left ventricular assist device? ASAIO J 2013; 58:509-13. [PMID: 22820918 DOI: 10.1097/mat.0b013e318260c6a6] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Blood stream infections (BSIs) are an important cause of morbidity and mortality in patients with left ventricular assist devices (LVADs). The aim of this study was to examine the correlation between hemorrhagic cerebrovascular accident (CVA) and BSI after implantation of LVAD for advanced heart failure (HF). This was a retrospective descriptive review of 87 patients with end-stage HF, who underwent implantation of HeartMate II continuous-flow LVAD over a 4 year period. Blood stream infections were diagnosed by serial blood cultures, and suspected neurological complications including CVAs were confirmed by neuroimaging. Extensive patient chart review was performed, and descriptive characteristics were analyzed using SPSS statistical software. The mean age of our study population was 62.3 ± 12.8 years, and the majority of our patients were males (n = 75, 86.2%). The baseline characteristics were comparable in the patients with and without CVAs. Patients with BSI had a much greater incidence of CVA compared to patients without BSI (n = 13, 43.3% vs. n = 5, 10.0%; p < 0.0001). There was an increased mortality in patients with BSI than those without (n = 57, 65.5% vs. n = 30, 34.5%; p = 0.003). The risk of all CVAs (hemorrhagic/ischemic) was eightfold (odds ratio [OR] = 7.9; 95% confidence interval [CI] = 2.4-25.5; p = 0.001] in patients with BSI. Patients with BSI had a >20-fold risk of hemorrhagic CVA (OR = 24; 95% CI = 2.8-201.1; p = 0.03). Advanced HF patients with LVAD support who developed BSI need urgent evaluation and close monitoring for suspected neurological complications, particularly hemorrhagic CVA.
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103
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Tonolini M, Ippolito S, Patella F, Petullà M, Bianco R. Hemorrhagic complications of anticoagulant therapy: role of multidetector computed tomography and spectrum of imaging findings from head to toe. Curr Probl Diagn Radiol 2013; 41:233-47. [PMID: 23009773 DOI: 10.1067/j.cpradiol.2012.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Highly effective in preventing and treating thromboembolic conditions in acute and chronic settings, anticoagulant therapy is associated with a non-negligible risk of hemorrhagic complications with a considerable clinical impact. Advanced age and comorbidities further increase the risk of bleeding during heparinization, treatment with low-molecular-weight heparins or long-term oral warfarin anticoagulation. Multidetector computed tomography represents the mainstay diagnostic technique to image-suspected hemorrhages in anticoagulated patients, as it can quickly assess presence, site, and extent of hemorrhage, identify active bleeding, and possible underlying diseases. Cross-sectional imaging appearances of the wide spectrum of anticoagulant therapy-related bleeding complications are hereby presented, including peripheral and thoracic-abdominal wall muscular hematomas, intrathoracic, abdominal, retroperitoneal genitourinary, gastrointestinal, and brain hemorrhages. Prompt recognition and comprehensive diagnostic assessment with multidetector computed tomography allow clinicians to correctly choose treatment modification or withdrawal, surgery, or interventional procedures as needed, with the aim to reduce the associated morbidity and mortality.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, Luigi Sacco University Hospital, Milan, Italy.
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104
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Peppard WJ, Peppard SR, Somberg L. Optimizing drug therapy in the surgical intensive care unit. Surg Clin North Am 2013; 92:1573-620. [PMID: 23153885 DOI: 10.1016/j.suc.2012.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article provides a review of commonly prescribed medications in the surgical ICU, focusing on sedatives, antipsychotics, neuromuscular blocking agents, cardiovascular agents, anticoagulants, and antibiotics. A brief overview of pharmacology is followed by practical considerations to aid prescribers in selecting the best therapy within a given category of drugs to optimize patient outcomes.
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Affiliation(s)
- William J Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI 53226, USA
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105
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Babu R, Bagley JH, Di C, Friedman AH, Adamson C. Thrombin and hemin as central factors in the mechanisms of intracerebral hemorrhage-induced secondary brain injury and as potential targets for intervention. Neurosurg Focus 2012; 32:E8. [PMID: 22463118 DOI: 10.3171/2012.1.focus11366] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intracerebral hemorrhage (ICH) is a subtype of stoke that may cause significant morbidity and mortality. Brain injury due to ICH initially occurs within the first few hours as a result of mass effect due to hematoma formation. However, there is increasing interest in the mechanisms of secondary brain injury as many patients continue to deteriorate clinically despite no signs of rehemorrhage or hematoma expansion. This continued insult after primary hemorrhage is believed to be mediated by the cytotoxic, excitotoxic, oxidative, and inflammatory effects of intraparenchymal blood. The main factors responsible for this injury are thrombin and erythrocyte contents such as hemoglobin. Therapies including thrombin inhibitors, N-methyl-D-aspartate antagonists, chelators to bind free iron, and antiinflammatory drugs are currently under investigation for reducing this secondary brain injury. This review will discuss the molecular mechanisms of brain injury as a result of intraparenchymal blood, potential targets for therapeutic intervention, and treatment strategies currently in development.
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Affiliation(s)
- Ranjith Babu
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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106
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Huhtakangas J, Tetri S, Juvela S, Saloheimo P, Bode MK, Karttunen V, Käräjämäki A, Hillbom M. Improved survival of patients with warfarin-associated intracerebral haemorrhage: a retrospective longitudinal population-based study. Int J Stroke 2012; 10:876-81. [PMID: 23231388 DOI: 10.1111/j.1747-4949.2012.00926.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Warfarin-associated intracerebral haemorrhage carries poor outcome due to rapid haemorrhage growth. Reversal of warfarin anticoagulation with prothrombin complex concentrate has been implemented as an acute treatment option for these subjects. AIM We investigated whether survival of subjects with warfarin-associated intracerebral haemorrhage had improved after implementation of reversal of warfarin anticoagulation with prothrombin complex concentrate. METHODS We identified all subjects with warfarin-associated intracerebral haemorrhage during 1993-2008 among the population of Northern Ostrobothnia, Finland. From 2004 onwards, prothrombin complex concentrate was used in Oulu University Hospital, the only hospital treating intracerebral haemorrhage subjects in the region, to counteract the effect of warfarin in subjects with warfarin-associated intracerebral haemorrhage. We compared the outcomes of subjects admitted during 1993-2003 and 2004-2008 and those treated and not treated with prothrombin complex concentrate. We also explored the predictors for one-year survival of the warfarin-associated intracerebral haemorrhage subjects. RESULTS We identified altogether 181 subjects who had intracerebral haemorrhage while on warfarin. One-year survival was significantly (P = 0·031) higher for the 60 subjects admitted during 2004-2008 (43·3%) than for the 121 admitted before 2004 (30·6%). In multivariable analysis, prothrombin complex concentrate treatment reduced one-year case fatality (hazard ratio 0·52, 95% confidence interval 0·29-0·93). Thromboembolic complications did not occur more frequently among those treated with prothrombin complex concentrate. CONCLUSION The survival of warfarin-associated intracerebral haemorrhage subjects among the population of Northern Ostrobothnia has improved likely because of introduction of prothrombin complex concentrate.
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Affiliation(s)
- Juha Huhtakangas
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Sami Tetri
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
| | - Seppo Juvela
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Pertti Saloheimo
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Michaela K Bode
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Vesa Karttunen
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Anni Käräjämäki
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Matti Hillbom
- Department of Neurology, Oulu University Hospital, Oulu, Finland
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107
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Abstract
Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain parenchyma and surrounding meningeal spaces. This article focuses on the acute diagnosis and management of primary nontraumatic intracerebral hemorrhage and subarachnoid hemorrhage in the emergency department.
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Affiliation(s)
- J Alfredo Caceres
- Department of Neurology, Massachusetts General Hospital, Suite 3B, Zero Emerson Place, Boston, MA 01940, USA
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108
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Delcourt C, Anderson C. Acute intracerebral haemorrhage: grounds for optimism in management. J Clin Neurosci 2012; 19:1622-6. [PMID: 23088860 DOI: 10.1016/j.jocn.2012.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 10/27/2022]
Abstract
Spontaneous intracerebral haemorrhage (ICH) is one of the most devastating types of stroke, which has considerable disease burden in "non-white" ethnic groups where the population-attributable risks of elevated blood pressure are very high. Since the treatment of ICH remains largely supportive and expectant, nihilism and the early withdrawal of active therapy influence management decisions in clinical practice. However, approaches to management are now better defined on the basis of evidence that both survival and speed (and degree) of recovery are critically dependent on the location, size, and degree of expansion and extension into the intraventricular system of the haematoma of the ICH. Although no medical treatment has been shown to improve outcome in ICH, several promising avenues have emerged that include haemostatic therapy and intensive control of elevated blood pressure. Conversely, there is continued controversy over the role of evacuation of the haematoma of ICH via open craniotomy. Despite being an established practice for several decades, and having undergone evaluation in multiple randomised trials, there is uncertainty over which patients have the most to gain from an intervention with clear procedural risk. Minimally invasive surgery via local anaesthetic applied drill-puncture of the cranium and infusion of a thrombolytic agent is an attractive option for patients requiring critical management of the haematoma, not just in low resource settings but arguably also in specialist centres of western countries. With several ongoing clinical trials nearing completion, these treatments could enter routine practice within the next few years, further justifying the urgency of "time is brain" and that active management within well-organized, comprehensive acute stroke care units includes patients with ICH.
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Affiliation(s)
- Candice Delcourt
- Neurological and Mental Health Division, The George Institute for Global Health, PO Box M201, Missenden Road, New South Wales 2050, Australia
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109
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Real world usage of PCC to "rapidly" correct warfarin induced coagulopathy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:500-5. [PMID: 23114527 DOI: 10.2450/2012.0113-12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/09/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Life threatening bleeding and emergency procedures in patients on vitamin K antagonists are indications for urgent reversal with prothrombin complex concentrate and vitamin K. Rapid reversal in these situations is emphasized in the literature and guidelines, but only very limited information is available on its real life use, especially on the timing of treatment in relation to presentation. MATERIALS AND METHODS We retrospectively audited emergency warfarin reversal in 131 consecutive patients. We studied the indication, use of vitamin K, time between presentation and administration of vitamin K and PCC, effectiveness in INR reduction and clinical outcome. RESULTS The median PCC dose was 26.8 IU/kg. The median INR was reduced from 3.1 to 1.2. Vitamin K (5 mg) was given in 91.6% of evaluable patients. We found significant delays in administration of PCC and vitamin K. The median time between presentation and administration of vitamin K/PCC was 3.6 and 5.2 hours respectively. The times in intracranial haemorrhage were 2.7 and 3.0 hours and in emergency procedures 17.4 and 15.9 hours respectively. Mortality related to bleeding was 7.6% overall but in patients with intracranial haemorrhage 22.8%. The thrombotic rate within 7 days of reversal was 1.5%. DISCUSSION The local protocol for reversal with PCC and vitamin K was adhered to well but the delay in pre-procedural patients, suggests that intravenous vitamin K alone may be sufficient in many cases and PCC administration can be avoided by better planning. Intracranial haemorrhage in warfarinised patients carries a high mortality. Treatment delays should be avoided by making PCC stocks available within emergency departments, simple dosing structures independent of INR and administering PCC without waiting for INR and CT scan results in those with strong suspicion of intracranial haemorrhage and clear trauma. Future reports and studies should always include the time from presentation to PCC treatment.
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110
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Desmettre T, Dehours E, Samama CM, Jhundoo S, Pujeau F, Guillaudin C, Hecquart C, Clerson P, Crave JC, Jaussaud R. Reversal of Vitamin K Antagonist (VKA) effect in patients with severe bleeding: a French multicenter observational study (Optiplex) assessing the use of Prothrombin Complex Concentrate (PCC) in current clinical practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R185. [PMID: 23036234 PMCID: PMC3682287 DOI: 10.1186/cc11669] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 10/04/2012] [Indexed: 11/10/2022]
Abstract
Introduction Prothrombin Complex Concentrate (PCC) is a key treatment in the management of bleeding related to Vitamin K antagonists (VKA). This study aimed to evaluate prospectively PCC use in patients with VKA-related bleeding in view of the French guidelines published in 2008. Methods All consecutive patients with VKA-related bleeding treated with a 4-factor PCC (Octaplex®) were selected in 33 French hospitals. Collected data included demographics, site and severity of bleeding, modalities of PCC administration, International Normalized Ratio (INR) values before and after PCC administration, outcomes and survival rate 15 days after infusion. Results Of 825 patients who received PCC between August 2008 and December 2010, 646 had severe bleeding. The main haemorrhage sites were intracranial (43.7%) and abdominal (24.3%). Mean INR before PCC was 4.4 ± 1.9; INR was unavailable in 12.5% of patients. The proportions of patients who received a PCC dose according to guidelines were 15.8% in patients with initial INR 2-2.5, 41.5% in patients with INR 2.5-3, 40.8% in patients with INR 3-3.5, 26.9% in patients with INR > 3.5, and 63.5% of patients with unknown INR. Vitamin K was administered in 84.7% of patients. The infused dose of PCC did not vary with initial INR; the mean dose was 25.3 ± 9.8 IU/Kg. Rates of controlled bleeding and target INR achievement were similar, regardless of whether or not patients were receiving PCC doses as per the guidelines. No differences in INR after PCC treatment were observed, regardless of whether or not vitamin K was administered. INR was first monitored after a mean time frame of 4.5 ± 5.6 hours post PCC. The overall survival rate at 15 days after PCC infusion was 75.4% (65.1% in patients with intracranial haemorrhage). A better prognosis was observed in patients reaching the target INR. Conclusions Severe bleeding related to VKA needs to be better managed, particularly regarding the PCC infused dose, INR monitoring and administration of vitamin K. A dose of 25 IU/kg PCC appears to be efficacious in achieving a target INR of 1.5. Further studies are required to assess whether adjusting PCC dose and/or better management of INR would improve outcomes.
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111
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Liotta EM, Garg RK, Temes RE, John S, Lee VH, Bleck TP, Prabhakaran S. Warfarin-Associated Intracerebral Hemorrhage Is Inadequately Treated at Community Emergency Departments. Stroke 2012; 43:2503-5. [DOI: 10.1161/strokeaha.112.664540] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eric M. Liotta
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Rajeev K. Garg
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Richard E. Temes
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Sayona John
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Vivien H. Lee
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Thomas P. Bleck
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
| | - Shyam Prabhakaran
- From the Section of Cerebrovascular Disease and Neurocritical Care (E.M.L., R.K.G., R.E.T., S.J., V.H.L., T.P.B.), Department of Neurological Sciences, Rush University Medical Center, Chicago, IL and Division of Cerebrovascular Disease (S.P.), Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, IL
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112
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Moussouttas M. Challenges and controversies in the medical management of primary and antithrombotic-related intracerebral hemorrhage. Ther Adv Neurol Disord 2012; 5:43-56. [PMID: 22276075 DOI: 10.1177/1756285611422267] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intracerebral hemorrhage (ICH) represents 10-15% of all cerebrovascular events, and is associated with substantial morbidity and mortality. In contrast to ischemic cerebrovascular disease in which acute therapies have proven beneficial, ICH remains a more elusive condition to treat, and no surgical procedure has proven to be beneficial. Aspects pertinent to medical ICH management include cessation or minimization of hematoma enlargement, prevention of intraventricular extension, and treatment of edema and mass effect. Therapies focusing on these aspects include prothrombotic (hemostatic) agents, antihypertensive strategies, and antiedema therapies. Therapies directed towards the reversal of antithrombosis caused by antiplatelet and anticoagulant agents are frequently based on limited data, allowing for diverse opinions and practice styles. Several newer anticoagulants that act by direct thrombin or factor Xa inhibition have no natural antidote, and are being increasingly used for various prophylactic and therapeutic indications. As such, these new anticoagulants will inevitably pose major challenges in the treatment of patients with ICH. Ongoing issues in the management of patients with ICH include the need for effective treatments that not only limit hematoma expansion but also result in improved clinical outcomes, the identification of patients at greatest risk for continued hemorrhage who may most benefit from treatment, and the initiation of therapies during the hyperacute period of most active hemorrhage. Defining hematoma volume increases at various anatomical locations that translate into clinically meaningful outcomes will also aid in directing future trials for this disease. The focus of this review is to underline and discuss the various controversies and challenges involved in the medical management of patients with primary and antithrombotic-related ICH.
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113
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Emiru T, Bershad EM, Zantek ND, Datta YH, Rao GHR, Hartley EW, Divani AA. Intracerebral hemorrhage: a review of coagulation function. Clin Appl Thromb Hemost 2012; 19:652-62. [PMID: 22904112 DOI: 10.1177/1076029612454938] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is associated with a higher mortality rate among stroke subtypes. The amount of hematoma at baseline and subsequent expansion are considered strong independent markers for determining poor clinical outcome. Even though reduction in blood pressure to prevent and control the amount of bleeding in ICH has received considerable amount of attention, the impact of coagulopathy and platelet dysfunction, on the bleeding diathesis has not been extensively investigated. With the increasing use of antiplatelets and/or anticoagulants, given the aging population, a deeper understanding of the interactions between ICH and hemostatic mechanisms is essential to help minimize the risk of a catastrophic coagulopathy-related ICH. In this review article, etiology and risk factors associated with coagulopathy-related ICH are discussed. An overview of coagulation abnormalities, hemostatic agents, and blood biomarkers pertaining to ICH is included.
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Affiliation(s)
- Tenbit Emiru
- 1Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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114
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Otero L, Zurita M, Bonilla C, Aguayo C, Rico MA, Vaquero J. [Perspectives of cell therapy in sequelae from cerebrovascular accidents]. Neurocirugia (Astur) 2012; 23:193-9. [PMID: 22858052 DOI: 10.1016/j.neucir.2011.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 10/28/2011] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Spontaneous intracerebral hemorrhage (ICH) is associated with mortality between 40 and 50% of cases. Among the survivors, only 10% are independent after one month, there is no effective treatment of sequelae, except for the limited possibilities providing for rehabilitation. OBJECTIVES We review the current experience with intracerebral transplantation of mesenchymal stem cells (MSCs) obtained from bone marrow as a potential treatment of neurological sequelae occurring after experimental ICH. MATERIAL AND METHODS We describe the model of ICH by intracerebral administration of collagenaseIV at basal ganglia level in Wistar rats. Neurological deficits caused by ICH can be quantified through a variety of functional assessment test (NMSS, Rota-rod, VTB-test). 5×10allogeneic MSCs in 10μl of saline were administered intracerebrally in 10 animals, 2 months after ICH. In another 10 animals (controls) the same volume of saline was administered. Changes in the functional deficits were assessed during the next 6 months in both experimental groups. RESULTS The results suggested therapeutic efficacy of MSCs transplantation and showed that transplanted stem cells can survive in the injured brain, transforming into neurons and glial cells. This form of cell therapy induces reactivation of endogenous neurogenesis at the subventricular zone (SVZ) and achieves antiapoptotic protective effect in the injured brain. CONCLUSIONS Cell therapy represents an important field of research with potential clinical application to treatment of neurological sequels, currently considered irreversible. Neurosurgeons should become involved in the development of these new techniques that are likely to shape the future of this specialty.
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Affiliation(s)
- Laura Otero
- Unidad de Investigación en Neurociencias y Cátedra Rafael del Pino de Neurociencias, Servicio de Neurocirugía, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Meretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S, Sairanen T, Satopää J, Silvennoinen H, Niemelä M, Kaste M, Tatlisumak T. SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage. Stroke 2012; 43:2592-7. [PMID: 22858729 DOI: 10.1161/strokeaha.112.661603] [Citation(s) in RCA: 228] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to provide a simple and practical clinical classification for the etiology of intracerebral hemorrhage (ICH). METHODS We performed a retrospective chart review of consecutive patients with ICH treated at the Helsinki University Central Hospital, January 2005 to March 2010 (n=1013). We classified ICH etiology by predefined criteria as structural vascular lesions (S), medication (M), amyloid angiopathy (A), systemic disease (S), hypertension (H), or undetermined (U). Clinical and radiological features and mortality by SMASH-U (Structural lesion, Medication, Amyloid angiopathy, Systemic/other disease, Hypertension, Undetermined) etiology were analyzed. RESULTS Structural lesions, namely cavernomas and arteriovenous malformations, caused 5% of the ICH, anticoagulation 14%, and systemic disease 5% (23 liver cirrhosis, 8 thrombocytopenia, and 17 various rare conditions). Amyloid angiopathy (20%) and hypertensive angiopathy (35%) were common, but etiology remained undetermined in 21%. Interrater agreement in classifying cases was high (κ, 0.89; 95% CI, 0.82-0.96). Patients with structural lesions had the smallest hemorrhages (median volume, 2.8 mL) and best prognosis (3-month mortality 4%), whereas anticoagulation-related ICHs were largest (13.4 mL) and most often fatal (54%). Overall, median ICH survival was 5½ years, varying strongly by etiology (P<0.001). After adjustment for baseline characteristics, patients with structural lesions had the lowest 3-month mortality rates (OR, 0.06; 95% CI, 0.01-0.37) and those with anticoagulation (OR, 1.9; 1.0-3.6) or other systemic cause (OR, 4.0; 1.6-10.1) the highest. CONCLUSIONS In our patients, performing the SMASH-U classification was feasible and interrater agreement excellent. A plausible etiology was determined in most patients but remained elusive in one in 5. In this series, SMASH-U based etiology was strongly associated with survival.
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Affiliation(s)
- Atte Meretoja
- Department of Neurology, Helsinki University Central Hospital, PO Box 340, FI-00029 HUS, Finland.
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Wozniak M, Kruit A, Padmore R, Giulivi A, Bormanis J. Prothrombin complex concentrate for the urgent reversal of warfarin. Assessment of a standard dosing protocol. Transfus Apher Sci 2012; 46:309-14. [DOI: 10.1016/j.transci.2012.03.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Leonardo CC, Robbins S, Doré S. Translating basic science research to clinical application: models and strategies for intracerebral hemorrhage. Front Neurol 2012; 3:85. [PMID: 22661966 PMCID: PMC3361857 DOI: 10.3389/fneur.2012.00085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 05/07/2012] [Indexed: 01/01/2023] Open
Abstract
Preclinical stroke models provide insights into mechanisms of cellular injury and potential therapeutic targets. Renewed efforts to standardize preclinical practices and adopt more rigorous approaches reflect the assumption that a better class of compounds will translate into clinical efficacy. While the need for novel therapeutics is clear, it is also critical that diagnostics be improved to allow for more rapid treatment upon hospital admission. Advances in imaging techniques have aided in the diagnosis of stroke, yet current limitations and expenses demonstrate the need for new and complementary approaches. Intracerebral hemorrhage (ICH) exhibits the highest mortality rate, displays unique pathology and requires specialized treatment strategies relative to other forms of stroke. The aggressive nature and severe consequences of ICH underscore the need for novel therapeutic approaches as well as accurate and expeditious diagnostic tools. The use of experimental models will continue to aid in addressing these important issues as the field attempts to translate basic science findings into the clinical setting. Several preclinical models of ICH have been developed and are widely used to recapitulate human pathology. Because each model has limitations, the burden lies with the investigator to clearly define the question being asked and select the model system that is most relevant to that question. It may also be necessary to optimize and refine pre-existing paradigms, or generate new paradigms, as the future success of translational research is dependent upon the ability to mimic human sequelae and assess clinically relevant outcome measures as means to evaluate therapeutic efficacy.
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Affiliation(s)
- Christopher C Leonardo
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida Gainesville, FL, USA
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Choi M, Hector M. Management of venous thromboembolism for older adults in long-term care facilities. ACTA ACUST UNITED AC 2012; 24:335-44. [DOI: 10.1111/j.1745-7599.2012.00733.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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119
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Vidal-Jordana A, Barroeta-Espar I, Sáinz Pelayo M, Mateo J, Delgado-Mederos R, Martí-Fàbregas J. Intracerebral haemorrhage in anticoagulated patients: What do we do afterwards? NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2012.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Tveiten A, Ljøstad U, Mygland Å, Thomassen L, Pripp AH, Naess H. Intracerebral Hemorrhage in Southern Norway – A Hospital-Based Incidence Study. Eur Neurol 2012; 67:240-5. [DOI: 10.1159/000336299] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 01/08/2012] [Indexed: 11/19/2022]
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Abstract
Intracerebral hemorrhage is a devastating disease, and no specific therapy has been proven to reduce mortality in a randomized controlled trial. However, management in a neuroscience intensive care unit does appear to improve outcomes, suggesting that many available therapies do in fact provide benefit. In the acute phase of intracerebral hemorrhage care, strategies aimed at minimizing ongoing bleeding include reversal of anticoagulation and modest blood pressure reduction. In addition, the monitoring and regulation of glucose levels, temperature, and, in selected cases, intracranial pressure are recommended by many groups. Selected patients may benefit from hematoma evacuation or external ventricular drainage. Ongoing clinical trials are examining aggressive blood pressure management, hemostatic therapy, platelet transfusion, stereotactic hematoma evacuation, and intraventricular thrombolysis. Finally, preventing recurrence of intracerebral hemorrhage is of pivotal importance, and tight blood pressure management is paramount.
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Affiliation(s)
- H Bart Brouwers
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Zhou W, Schwarting S, Illanes S, Liesz A, Middelhoff M, Zorn M, Bendszus M, Heiland S, van Ryn J, Veltkamp R. Hemostatic Therapy in Experimental Intracerebral Hemorrhage Associated With the Direct Thrombin Inhibitor Dabigatran. Stroke 2011; 42:3594-9. [DOI: 10.1161/strokeaha.111.624650] [Citation(s) in RCA: 277] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Purpose—
Dabigatran-etexilate (DE) recently has been approved for stroke prevention in atrial fibrillation. However, lack of effective antagonists represents a major concern in the event of intracerebral hemorrhage (ICH). The aims of the present study were to establish a murine model of ICH associated with dabigatran, and to test the efficacy of different hemostatic factors in preventing hematoma growth.
Methods—
In C57BL/6 mice receiving DE (4.5 or 9.0 mg/kg), in vivo and in vitro coagulation assays and dabigatran plasma levels were measured repeatedly. Thirty minutes after inducing ICH by striatal collagenase injection, mice received an intravenous injection of saline, prothrombin complex concentrate (PCC; 100 U/kg), murine fresh-frozen plasma (200 μL), or recombinant human factor VIIa (8.0 mg/kg). ICH volume was quantified on brain cryosections 24 hours later.
Results—
DE substantially prolonged tail vein bleeding time and ecarin clotting time for 4 hours corresponding to dabigatran plasma levels. Intracerebral hematoma expansion was observed mainly during the first 3 hours on serial T2* MRI. Anticoagulation with high doses of DE increased the hematoma volume significantly. PCC and, less consistently, fresh-frozen plasma prevented excess hematoma expansion caused by DE, whereas recombinant human factor VIIa was ineffective. Prevention of hematoma growth and reversal of tail vein bleeding time by PCC were dose-dependent.
Conclusions—
The study provides strong evidence that PCC and, less consistently, fresh-frozen plasma prevent excess intracerebral hematoma expansion in a murine ICH model associated with dabigatran. The efficacy and safety of this strategy must be further evaluated in clinical studies.
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Affiliation(s)
- Wei Zhou
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sönke Schwarting
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sergio Illanes
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Arthur Liesz
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Moritz Middelhoff
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Markus Zorn
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martin Bendszus
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sabine Heiland
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Joanne van Ryn
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Roland Veltkamp
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
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Cervera A, Chamorro A. Antithrombotic therapy in cardiac embolism. Curr Cardiol Rev 2011; 6:227-37. [PMID: 21804782 PMCID: PMC2994115 DOI: 10.2174/157340310791658749] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 01/18/2023] Open
Abstract
Anticoagulation is indicated in most cardioembolic ischemic strokes for secondary prevention. In many cardiac conditions, anticoagulation is also indication for primary stroke prevention, mainly when associated to vascular risk factors. Anticoagulation should be started as soon as possible, as it is safe even in moderate acute strokes. The efficacy of early anticoagulation after cardioembolic stroke in relation to outcome has not been assessed adequately, but there is evidence from animal models and clinical studies that anticoagulation with unfractionated heparin is associated with a better outcome mediated in part by its anti-inflammatory properties.
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Affiliation(s)
- Alvaro Cervera
- Comprehensive Stroke Center, Hospital Clínic; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona, Spain
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125
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Abstract
Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuro-monitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.
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Affiliation(s)
- Andrew M Naidech
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Schlunk F, Van Cott EM, Hayakawa K, Pfeilschifter W, Lo EH, Foerch C. Recombinant activated coagulation factor VII and prothrombin complex concentrates are equally effective in reducing hematoma volume in experimental warfarin-associated intracerebral hemorrhage. Stroke 2011; 43:246-9. [PMID: 21998055 DOI: 10.1161/strokeaha.111.629360] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Based on an experimental model of warfarin-associated intracerebral hemorrhage, we investigated whether the rapid reversal of anticoagulation using prothrombin complex concentrates (PCC) or recombinant activated coagulation factor VII (rFVIIa) reduces hematoma volume. METHODS Mice were orally pretreated with warfarin (2 mg/kg). Intracerebral hemorrhage was induced by collagenase injection into the right striatum. Forty-five minutes later, PCC (100 IE/kg), rFVIIa (1 mg/kg), or an equal volume of saline was administered intravenously. Hematoma volume after 24 hours was quantified using a photometric hemoglobin assay. RESULTS International normalized ratio was 4.3±0.4 in saline-treated mice, 0.9±0.1 in rFVIIa mice, and 1.4±0.2 in PCC mice. Intracerebral hemorrhage volume was 29.0±19.7 μL in the saline group (n=7), 8.6±4.3 μL in the rFVIIa group (n=6), and 6.1±1.8 μL in the PCC group (n=7; analysis of variance between-group differences P=0.004; post hoc rFVIIa versus saline P=0.021; PCC versus saline P=0.007). No significant difference was found between PCC- and rFVIIa-treated animals. CONCLUSIONS Our results suggest that PCC and rFVIIa are equally effective in restoring coagulation and preventing excessive hematoma growth in acute warfarin-associated intracerebral hemorrhage.
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Affiliation(s)
- Frieder Schlunk
- Department of Neurology, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
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127
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Steiner T, Petersson J, Al-Shahi Salman R, Christensen H, Cordonnier C, Csiba L, Harnof S, Krieger D, Mendelow D, Molina C, Montaner J, Overgaard K, Roine RO, Schmutzhard E, Tatlisumak T, Toni D, Stapf C. European research priorities for intracerebral haemorrhage. Cerebrovasc Dis 2011; 32:409-19. [PMID: 21986448 DOI: 10.1159/000330653] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 07/01/2011] [Indexed: 12/31/2022] Open
Abstract
Over 2 million people are affected by intracerebral haemorrhage (ICH) worldwide every year, one third of them dying within 1 month, and many survivors being left with permanent disability. Unlike most other stroke types, the incidence, morbidity and mortality of ICH have not declined over time. No standardised diagnostic workup for the detection of the various underlying causes of ICH currently exists, and the evidence for medical or surgical therapeutic interventions remains limited. A dedicated European research programme for ICH is needed to identify ways to reduce the burden of ICH-related death and disability. The European Research Network on Intracerebral Haemorrhage EURONICH is a multidisciplinary academic research collaboration that has been established to define current research priorities and to conduct large clinical studies on all aspects of ICH.
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Affiliation(s)
- Thorsten Steiner
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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Lauer A, Cianchetti FA, Van Cott EM, Schlunk F, Schulz E, Pfeilschifter W, Steinmetz H, Schaffer CB, Lo EH, Foerch C. Anticoagulation with the oral direct thrombin inhibitor dabigatran does not enlarge hematoma volume in experimental intracerebral hemorrhage. Circulation 2011; 124:1654-62. [PMID: 21911784 DOI: 10.1161/circulationaha.111.035972] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The direct thrombin inhibitor dabigatran etexilate (DE) may constitute a future replacement of vitamin K antagonists for long-term anticoagulation. Whereas warfarin pretreatment is associated with greater hematoma expansion after intracerebral hemorrhage (ICH), it remains unclear what effect direct thrombin inhibitors would have. Using different experimental models of ICH, this study compared hematoma volume among DE-treated mice, warfarin-treated mice, and controls. METHODS AND RESULTS CD-1 mice were fed with DE or warfarin. Sham-treated mice served as controls. At the time point of ICH induction, DE mice revealed an increased activated partial thromboplastin time compared with controls (mean±SD 46.1 ± 5.0 versus 18.0 ± 1.5 seconds; P=0.022), whereas warfarin pretreatment resulted in a prothrombin time prolongation (51.4 ± 17.9 versus 10.4 ± 0.3 seconds; P<0.001). Twenty-four hours after collagenase-induced ICH formation, hematoma volume was 3.8 ± 2.9 μL in controls, 4.8 ± 2.7 μL in DE mice, and 14.5 ± 11.8 μL in warfarin mice (n=16; Welch ANOVA between-group differences P=0.007; posthoc analysis with the Dunnett method: DE versus controls, P=0.899; warfarin versus controls, P<0.001; DE versus warfarin, P=0.001). In addition, a model of laser-induced cerebral microhemorrhage was applied, and the distances that red blood cells and blood plasma were pushed into the brain were quantified. Warfarin mice showed enlarged red blood cell and blood plasma diameters compared to controls, but no difference was found between DE mice and controls. CONCLUSIONS In contrast with warfarin, pretreatment with DE did not increase hematoma volume in 2 different experimental models of ICH. In terms of safety, this observation may represent a potential advantage of anticoagulation with DE over warfarin.
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Affiliation(s)
- Arne Lauer
- Department of Neurology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
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[Intensive care management [corrected] of patients with intracerebral hemorrhage]. DER NERVENARZT 2011; 82:431-2, 434-6, 438-46. [PMID: 21431439 DOI: 10.1007/s00115-010-3072-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.
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Huhtakangas J, Tetri S, Juvela S, Saloheimo P, Bode MK, Hillbom M. Effect of Increased Warfarin Use on Warfarin-Related Cerebral Hemorrhage. Stroke 2011; 42:2431-5. [DOI: 10.1161/strokeaha.111.615260] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Juha Huhtakangas
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
| | - Sami Tetri
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
| | - Seppo Juvela
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
| | - Pertti Saloheimo
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
| | - Michaela K. Bode
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
| | - Matti Hillbom
- From the Departments of Neurology (J.H., P.S., M.H.), Neurosurgery (S.T.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital, Oulu, Finland; and Clinical Neurosciences (S.J.), University of Helsinki, Helsinki, Finland
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Lauer A, Schlunk F, Van Cott EM, Steinmetz H, Lo EH, Foerch C. Antiplatelet pretreatment does not increase hematoma volume in experimental intracerebral hemorrhage. J Cereb Blood Flow Metab 2011; 31:1736-42. [PMID: 21386857 PMCID: PMC3170939 DOI: 10.1038/jcbfm.2011.22] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 01/11/2011] [Accepted: 02/02/2011] [Indexed: 11/09/2022]
Abstract
While oral anticoagulants are associated with greater hematoma expansion and higher mortality rates in patients with intracerebral hemorrhage (ICH), there is ongoing discussion whether pretreatment with antiplatelet drugs also worsens prognosis. Using an experimental model of ICH, we investigated the effects of antiplatelet pretreatment on hematoma volume and functional outcome. CD-1 mice were treated with acetyl-salicylic acid (ASA, 60 mg/kg per 24 hours), clopidogrel (22.5 mg/kg per 24 hours), or both (ASA+clopidogrel) through drinking water for 3 days (n=20 per group). Thereafter, platelet aggregation was found to be significantly reduced. Untreated mice and mice pretreated with warfarin served as controls. A stereotactic injection of collagenase into the right striatum was used to induce ICH. Twenty-four hours after ICH induction, hematoma volume was measured to be 15.0 ± 4.4 μL in controls, 14.1 ± 5.3 μL in ASA mice, 16.8 ± 5.1 μL in clopidogrel mice, and 16.4 ± 5.1 μL in ASA+clopidogrel animals. These differences were not statistically significant. However, mice pretreated with warfarin revealed largely increased hematoma volumes (25.0 ± 7.4 μL versus controls, P=0.001). Neurologic outcome was not different between antiplatelet-pretreated animals and untreated controls. Our results suggest that plasmatic coagulation rather than platelet function is the most critical element for preventing hematoma expansion in acute ICH. Future therapeutic strategies may take these findings into account.
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Affiliation(s)
- Arne Lauer
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frieder Schlunk
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth M Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Helmuth Steinmetz
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Foerch
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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132
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Abstract
BACKGROUND Intracerebral hemorrhage (ICH) care can vary among centers and previous studies have demonstrated differences in ICH outcome based on variations in patient care in various settings. The purpose of this paper is to present the design of an evidence-based dataset of elements of a new ICH specific intensity of care quality metrics. METHODS The articles were identified based on personal knowledge of the subject supplemented by data derived from multi-center randomized trials, and selected non-randomized or observational clinical studies. The information was identified with multiple searches on MEDLINE from 1986 through 2009. The current guidelines from American Heart Association (AHA)/American Stroke Association (ASA) Stroke Council and The European Stroke Initiative (EUSI) Writing Committee for management of ICH were reviewed extensively for identifying quality indicators and available scientific evidence. For certain elements where stroke-specific data was not available, data derived from other disease process with direct relevance was used. RESULTS A total of 26 quality indicators related to 18 facets of care with thresholds for quality response were identified. A pilot study was performed to asses and score 1300 (26 indicator per patientX25 patientsX2 raters) quality indicators. The minimum proportion of patients meeting quality parameter ranged from 44% to 100% depending upon the variable. The lowest performance scores were observed in the early intubation and mechanical ventilation, treatment of significant intracranial mass effect or transtentorial herniation, and timely acquisition of neuroimaging. The highest performance scores were seen in treatment of any seizure within 2 weeks of admission, status epilepticus, and prevention of gastric ulcer. CONCLUSIONS The next step in development of a new ICH specific intensity of care quality metrics is validation and refinement of the quality indicators and thresholds presented in the current report. Future activities may include selection and validation based on consensus of experts and application of the system to a large series of patients with ICH and assessment of relationship of components in isolation and as a group to outcome after severity adjustment.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, 12-100 PWB, 516 Delaware St. SE, Minneapolis, MN 55455, USA.
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Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review. Int J Emerg Med 2011; 4:40. [PMID: 21740550 PMCID: PMC3141388 DOI: 10.1186/1865-1380-4-40] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 07/08/2011] [Indexed: 12/01/2022] Open
Abstract
Study objective The acute management of patients on warfarin with spontaneous or traumatic intracranial hemorrhage continues to be debated in the medical literature. The objective of this paper was to conduct a structured review of the medical literature and summarize the advantages and risks of the available treatment options for reversing warfarin anticoagulation in patients who present to the emergency department with acute intracranial hemorrhage. Methods A structured literature search and review of articles relevant to intracranial hemorrhage and warfarin and treatment in the emergency department was performed. Databases for PubMed, CINAHL, and Cochrane EBM Reviews were electronically searched using keywords covering the concepts of anticoagulation drugs, intracranial hemorrhage (ICH), and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The multiple database searches revealed 586 papers for review for possible inclusion. The final consensus of our comprehensive search strategy was a total of 23 original studies for inclusion in our review. Results Warfarin not only increases the risk of but also the severity of ICH by causing hematoma expansion. Prothrombin complex concentrate is statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions. Recombinant factor VIIa appears to rapidly reverse warfarin's effect on INR; however, this treatment is not FDA-approved and is associated with a 5% thromboembolic event rate. Slow intravenous dosing of vitamin K is recommended in patients with ICH. The 30-day risk for ischemic stroke after discontinuation of warfarin therapy was 3-5%. The risks of not reversing the anticoagulation in ICH generally outweigh the risk of thrombosis in the acute setting. Conclusions Increasing numbers of patients are on anticoagulation including warfarin. There is no uniform standard for reversing warfarin in intracranial hemorrhage. Intravenous vitamin K in addition to fresh frozen plasma or prothrombin complex concentrate is recommended be used to reverse warfarin-associated intracranial hemorrhage. No mortality benefit for one treatment regimen over another has been shown. Emergency physicians should know their hospital's available warfarin reversal options and be comfortable administering these treatments to critically ill patients.
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134
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Cervera Á, Amaro S, Chamorro Á. Oral anticoagulant-associated intracerebral hemorrhage. J Neurol 2011; 259:212-24. [DOI: 10.1007/s00415-011-6153-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 06/16/2011] [Indexed: 12/18/2022]
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Font MÀ, Krupinski J, Arboix A. Antithrombotic medication for cardioembolic stroke prevention. Stroke Res Treat 2011; 2011:607852. [PMID: 21822469 PMCID: PMC3148601 DOI: 10.4061/2011/607852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 03/02/2011] [Accepted: 03/27/2011] [Indexed: 01/28/2023] Open
Abstract
Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed.
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Affiliation(s)
- M. Àngels Font
- Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Department of Neurology, Hospital Sant Joan de Déu de Manresa (Fundació Althaia), Catalonia, 08243 Manresa, Spain
| | - Jerzy Krupinski
- Department of Neurology, Cerebrovascular Diseases Unit, Hospital Universitari Mútua de Terrassa, Catalonia, 08227 Terrassa, Spain
| | - Adrià Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari Sagrat Cor, University of Barcelona, C/Viladomat 288, Catalonia, 08029 Barcelona, Spain
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Vidal-Jordana A, Barroeta-Espar I, Sáinz Pelayo MP, Mateo J, Delgado-Mederos R, Martí-Fàbregas J. [Intracerebral hemorrhage in anticoagulated patients: what do we do afterwards?]. Neurologia 2011; 27:136-42. [PMID: 21683480 DOI: 10.1016/j.nrl.2011.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 04/22/2011] [Accepted: 04/27/2011] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION The management of antithrombotic therapy after intracerebral hemorrhage (ICH) in anticoagulated patients is not well defined. We analyzed the risks and benefits of antiplatelet therapy (AG) against the resumption of anticoagulation with vitamin K antagonists (AVK) in a series of patients. MATERIAL AND METHODS Retrospective study of ICH in anticoagulated patients. We registered demographic data, history of hypertension (HT), time of follow-up and new cerebral vascular events (ICH, stroke [IC]). RESULTS We evaluated 88 patients, mean age 69±9 years, 50% men, 73% hypertensive. During the acute phase 18 patients died and the follow-up was lost in 31. Of the remaining (n=39), AVKs were resumed in 25 and changed to AG in 14. Comparing the characteristics of both groups, the anticoagulated group was younger (P=.005) and the embolic sources were more often of higher risk (P=.003). After an average follow-up of 54±31 months, the distribution of events was: IC (AVKs 8%, AG 14.3%, P=.6), ICH (AVKs 24%, AG 7.1%, P=.38), IC or ICH (AVKs 32%, AG 21.4%, P=.48) and death (AVKs 29%, AG 7.1%, P=.21). This trend of increased risk of new events in patients with AVKs was confirmed by Kaplan-Meier curves, although without statistical differences. CONCLUSIONS Restarting AVK treatment after ICH in anticoagulated patients could increase the risk of new bleeding events and mortality. Prospective studies are needed to define a better and appropriate antithrombotic therapy after ICH related with anticoagulation.
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Affiliation(s)
- A Vidal-Jordana
- Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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137
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Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med 2011; 77:791-9. [PMID: 21048052 DOI: 10.3949/ccjm.77a.10018] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intracerebral hemorrhage (ICH) is the most feared and the most deadly complication of oral anticoagulant therapy, eg, with warfarin (Coumadin). After such an event, clinicians wonder whether their patients should resume anticoagulant therapy. The authors review the management of anticoagulation during and after anticoagulation-associated ICH.
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Affiliation(s)
- Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
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138
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Intracranial hemorrhage surgery on patients on mechanical circulatory support: a case series. J Neurosurg Anesthesiol 2011; 23:30-4. [PMID: 20706140 DOI: 10.1097/ana.0b013e3181eee55e] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac disease is the leading cause of death in the United States and late-stage heart failure is associated with a high level of morbidity and mortality. The ventricular assist devices and extracorporeal membrane oxygenators are the mainstay of mechanical circulatory support devices for the patients with extremely low cardiac output. However, they come at a price of significant risk factors, including intracranial hemorrhage. The incidence of intracranial hemorrhage on extracorporeal membrane oxygenators and on ventricular assist devices is 37% and 13% to 14%, respectively. METHODS/RESULTS The cases in this series focus on the risks of ICH and the decompressive craniotomies that were carried out on patients while they were on mechanical circulatory support. The intraoperative anesthetic management for patients on mechanical circulatory support for the noncardiothoracic anesthesiologist is highlighted. CONCLUSIONS The results of recent cardiothoracic surgery trials have led to an increase of surgical management instead of medical management in the treatment of heart failure. Although most agree with the immediate reversal of anticoagulation and antiplatelet therapy, there is no standard protocol for restarting anticoagulation or antiplatelet therapy after craniotomy in this population. The standard practices of resuscitation and ACLS including inotropes, vasopressors, and vasodilators (with the exception of chest compressions that can dislodge the devices), can be used as needed. The identification of cardiothoracic surgeons and perfusionists who are available for immediate assistance as and when required during the surgery and transportation is an important factor.
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Abstract
BACKGROUND The purpose of this study is to determine whether intraventricular hemorrhage (IVH) exerts a "decompressive" effect that limits intracerebral hemorrhage (ICH) enlargement. METHODS Retrospective review of patients with spontaneous supratentorial ICH diagnosed within 6 h of onset, who underwent follow-up head CT approximately 48 h later. Digital imaging analysis of CT scans was performed to compare hematoma volume changes between patients with and without IVH. Hemorrhage locations were classified as paraventricular (PV) or non-PV. Regression analyses were employed to identify predictors of IVH, hematoma expansion, and mortality. RESULTS Of the 70 patients included 57% developed IVH, 85% of which occurred before initial CT. 71% of PV hemorrhages developed IVH, all before initial CT, and 48% of non-PV hemorrhages developed IVH, 29% of which occurred after initial CT. IVH was associated with PV location (P = 0.04), and among IVH patients PV location was associated with early IVH (P = 0.003). Predictors of mortality included age (P = 0.037), initial hematoma volume (P < 0.04), absolute volume change (P = 0.01), and final hematoma volume (P < 0.001). Variables predicting IVH included PV location (P < 0.0001), larger initial hematoma volume (P = 0.002), and greater absolute volume increase (P = 0.01). Hematoma expansion was greatest for non-PV with IVH (P = 0.08), and graphic inspection suggested that ICH volume tended to decrease with PV location and increase with IVH. Final hematoma volume was associated with initial volume (P < 0.0001), non-PV location (P = 0.02), and IVH (P = 0.04). CONCLUSIONS IVH was not associated with less hematoma volume expansion, and for non-PV hemorrhages IVH was linked to greater volume increase.
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Masotti L, Di Napoli M, Godoy DA, Rafanelli D, Liumbruno G, Koumpouros N, Landini G, Pampana A, Cappelli R, Poli D, Prisco D. The practical management of intracerebral hemorrhage associated with oral anticoagulant therapy. Int J Stroke 2011; 6:228-40. [PMID: 21557810 DOI: 10.1111/j.1747-4949.2011.00595.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.
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Rizos T, Jenetzky E, Herweh C, Unterberg A, Hacke W, Veltkamp R. Fast point-of-care coagulometer guided reversal of oral anticoagulation at the bedside hastens management of acute subdural hemorrhage. Neurocrit Care 2011; 13:321-5. [PMID: 20878267 DOI: 10.1007/s12028-010-9443-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency reversal of the international normalized ratio (INR) in patients who develop nontraumatic subdural hemorrhage (SDH) due to oral anticoagulants (OAC) represents a primary treatment strategy but it is difficult to predict the amount of prothrombin complex concentrate (PCC) needed for reversal treatment. Moreover, repeated INR testings in central laboratories (CL) are time consuming. The usefulness of point-of-care INR coagulometers (POC) to test the success of INR reversal in OAC-SDH has not yet been investigated. METHODS Prospectively, INR reversal was performed by administering PCC to patients suffering from acute SDH-OAC using a predefined dosing schedule. Accuracy and time gained by using POC were assessed and compared with CL measurements. RESULTS A total of 10 patients were treated according to the protocol (male: 5). Bland-Altman analysis between POC and CL revealed a mean INR deviation of 0.013 for initial INR values and of 0.081 during reversal treatment. Using POC, the median initial net time gain (accounting for clinical examination and CT) for the start of PCC was 21 min. Median total time for POC-documented reversal was 27 min, as compared to 70 min for CL. The shortest interval between head CT and start of emergency SDH evacuation surgery was 37 min. By employing stepwise POC-guided reversal of the anticoagulatory effect of OAC, the calculated PCC dose could be reduced by 25% in the median. CONCLUSIONS Using POC to measure INR values and patient-adapted PCC administration is a fast and economic method to reverse anticoagulation in patients with acute OAC-SDH.
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Affiliation(s)
- Timolaos Rizos
- Department of Neurology, University Heidelberg, INF 400, 69120, Heidelberg, Germany
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Esperienza clinica nella gestione dell’emorragia intracranica spontanea in pazienti in terapia con warfarin. ITALIAN JOURNAL OF MEDICINE 2011. [DOI: 10.1016/j.itjm.2010.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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143
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Leifer D, Bravata DM, Connors J(B, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R. Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations. Stroke 2011; 42:849-77. [DOI: 10.1161/str.0b013e318208eb99] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Steiner T, Freiberger A, Griebe M, Hüsing J, Ivandic B, Kollmar R, Pfefferkorn T, Wartenberg KE, Weimar C, Hennerici M, Poli S. International normalised ratio normalisation in patients with coumarin-related intracranial haemorrhages--the INCH trial: a randomised controlled multicentre trial to compare safety and preliminary efficacy of fresh frozen plasma and prothrombin complex--study design and protocol. Int J Stroke 2011; 6:271-7. [PMID: 21557816 DOI: 10.1111/j.1747-4949.2010.00560.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intracerebral haemorrhage is the most feared complication in patients who are on treatment with vitamin K antagonists. Vitamin K antagonist related intracerebral haemorrhage occurs in about 10% of patients. Intracerebral haemorrhage has the worst prognosis of all subtypes of stroke including spontaneous intracerebral haemorrhage, and a mortality rate of up to about 65%. The higher rate of haematoma expansion due to rebleeding is thought to be responsible for the higher mortality. Current international treatment recommendations include fresh frozen plasma and prothrombin complex concentrate. It is known that these substances lower the international normalised ratio, and thus it is assumed that normalisation of coagulopathy may lead to haemostasis and reduction of rebleeding. However, the issue of whether to use fresh frozen plasma or prothrombin complex concentrate for urgent reversal of vitamin K antagonists is unresolved: safety and efficacy of these treatments have never been studied in a randomised controlled trial. Our questions are: how effective are the two substances in normalisation of the international normalized ratio? How feasible is it to apply either of these treatments in an acute situation? What is the safety profile of each of these substances? Is there a difference in haematoma growth and clinical outcome? METHOD We designed a prospective, randomised, controlled multicentre trial to compare biological efficacy and safety of fresh frozen plasma and prothrombin complex concentrate in vitamin K antagonist related intracerebral haemorrhage. The study is observer-blinded for laboratory, neuroradiological, and clinical outcomes. Patients will be included if a computed tomography scan shows an intraparenchymal or subdural haematoma within 12 h after onset of symptoms, if the patient is on treatment with vitamin K antagonists, and the international normalized ratio is ≥2. Primary endpoint is the normalisation of the international normalized ratio (≤1·2) within three-hours after the start of antagonising therapy. Main exclusion criteria are secondary intracerebral haemorrhage, other known coagulopathies, and known acute ischaemic events. DISCUSSION We discuss the rationale of our trial on the basis of the current recommendations and specific aspects of trial design as, time window, choice of endpoints, dosing of fresh frozen plasma and prothrombin complex concentrate, monitoring and analysis of safety parameters, and rescue treatment. CONCLUSION This will be the first prospective trial comparing fresh frozen plasma and prothrombin complex concentrate in the indication of vitamin K antagonist related intracerebral hemorrhage. Recruitment of subjects started in August 2009. Until now, 19 patients have been included.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
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Illanes S, Zhou W, Schwarting S, Heiland S, Veltkamp R. Comparative effectiveness of hemostatic therapy in experimental warfarin-associated intracerebral hemorrhage. Stroke 2010; 42:191-5. [PMID: 21127298 DOI: 10.1161/strokeaha.110.593541] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE intracerebral hemorrhage associated with oral anticoagulants has a poor prognosis. Current treatment guidelines are based on case series and plausibility only, and a common consensus on effective hemostatic therapy is missing. We compared the effectiveness of diverse hemostatic approaches in a mouse model of warfarin-associated intracerebral hemorrhage. METHODS male C57BL/6 mice received anticoagulant treatment with warfarin (0.4 mg/kg for 3 days). Intracerebral hemorrhage was induced by striatal injection of collagenase, and 30 minutes later, mice received an intravenous injection of saline (200 μL n=15), prothrombin complex concentrate (100 U/kg, n=10), fresh-frozen plasma (200 μL, n=13), recombinant human Factor VII activated (3.5 mg/kg, n=8 and 10 mg/kg, n=8), or tranhexamic acid (400 mg/kg, n=12). Intracerebral hemorrhage volume was quantified on T2-weighted images after 24 hours. RESULTS mean hematoma volumes were 7.4 ± 1.8 mm(3) in the nonwarfarin controls and 21.9 ± 5.0 mm(3) in the warfarin group receiving saline. Prothrombin complex concentrate (7.5 ± 2.3 mm(3)) and fresh-frozen plasma (8.7 ± 2.1) treatment resulted in significantly smaller hematoma volume compared with saline. Recombinant human Factor VII activated (10 mg/kg: 14.7 ± 3.4; 3.5 mg/kg: 15.0 ± 6.8 mm(3)) and tranexamic acid (16.2 ± 4.1 mm(3)) were less effective. Water content in the hemorrhagic hemisphere was similar in all groups except for tranexamic acid in which it was significantly increased. CONCLUSIONS prothrombin complex concentrate and fresh-frozen plasma effectively prevent hematoma growth in murine warfarin-associated intracerebral hemorrhage, whereas Factor VIIa was less effective. Tranexamic acid exacerbates perihematoma edema in this mouse warfarin-associated intracerebral hemorrhage model.
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Affiliation(s)
- Sergio Illanes
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
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Lee K, Hoots WK. Human plasma-derived concentrates: preventing thrombosis and controlling haemorrhage. Haemophilia 2010; 16:949-951. [PMID: 20546032 DOI: 10.1111/j.1365-2516.2010.02331.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- K Lee
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, Halperin JL, Johnston SC, Katzan I, Kernan WN, Mitchell PH, Ovbiagele B, Palesch YY, Sacco RL, Schwamm LH, Wassertheil-Smoller S, Turan TN, Wentworth D. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2010; 42:227-76. [PMID: 20966421 DOI: 10.1161/str.0b013e3181f7d043] [Citation(s) in RCA: 1133] [Impact Index Per Article: 80.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.
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Prothrombin Complex Concentrate for Rapid Reversal of Warfarin-induced Anticoagulation and Intracerebral Hemorrhage in Patients Supported by a Left Ventricular Assist Device. INT J GERONTOL 2010. [DOI: 10.1016/s1873-9598(10)70038-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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150
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Parker D, Rhoney DH, Liu-DeRyke X. Management of spontaneous nontraumatic intracranial hemorrhage. J Pharm Pract 2010; 23:398-407. [PMID: 21507845 DOI: 10.1177/0897190010372320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke and is characterized by spontaneous extravasation into the parenchymal tissue of the brain. Although advances in critical care have improved, there is no intervention currently available that has shown to alter the outcome of patients who have suffered acute ICH. Therefore, management is largely supportive. Treatment strategies are aimed at limiting hematoma enlargement, seizures, and cerebral edema, as well as other ICU-related complications such as deep venous thrombosis, hyperglycemia, and fever. This review will outline the key pharmacological management strategies in patients with ICH and highlight the most current American Heart Association/American Stroke Association (AHA/ASA) guidelines for management published in 2007.
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Affiliation(s)
- Dennis Parker
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA.
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