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Yeager CE, Garg RK. Advances and Future Trends in the Diagnosis and Management of Intracerebral Hemorrhage. Neurol Clin 2024; 42:689-703. [PMID: 38937036 DOI: 10.1016/j.ncl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Spontaneous intracerebral hemorrhage accounts for approximately 10% to 15% of all strokes in the United States and remains one of the deadliest. Of concern is the increasing prevalence, especially in younger populations. This article reviews the following: epidemiology, risk factors, outcomes, imaging findings, medical management, and updates to surgical management.
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Affiliation(s)
- Christine E Yeager
- Division of Critical Care Neurology, Rush University Medical Center, 1725 W Harrison Street, Suite 1106, Chicago, IL, USA.
| | - Rajeev K Garg
- Division of Critical Care Neurology, Section of Cognitive Neurosciences, Rush University Medical Center, 1725 W Harrison Street, Suite 1106, Chicago, IL, USA
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Shahzad F, Ahmed U, Muhammad A, Shahzad F, Naufil SI, Sukkari MW, Kamran AB, Murtaza S, Khalid MB, Shabbir H, Saeed S. Safety and efficacy of desmopressin (DDAVP) in preventing hematoma expansion in intracranial hemorrhage associated with antiplatelet drugs use: A systematic review and metaanalysis. Brain Behav 2024; 14:e3540. [PMID: 38778788 PMCID: PMC11112402 DOI: 10.1002/brb3.3540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION One of the most serious complications associated with antiplatelet agents is antiplatelet-associated intracranial hemorrhage (AA-ICH). Desmopressin is a synthetic antidiuretic hormone (ADH) analog. It has been linked to improving patient outcomes in antiplatelet-induced intracranial hemorrhage. The secondary outcomes included the incidence of thrombotic complications and neurological outcomes. METHODS A systematic search was conducted on three databases (PubMed, Cochrane, and ClinicalTrials.gov) to find eligible literature that compares desmopressin (DDAVP) versus controls in patients with AA-ICH. The Mantel-Haenszel statistic was used to determine an overall effect estimate for each outcome by calculating the risk ratios and 95% confidence intervals (CI). Heterogeneity was measured using the I2 test. The risk of bias in studies was calculated using the New Castle Ottowa Scale. RESULTS Five studies were included in the analysis with a total of 598 patients. DDAVP was associated with a nonsignificant decrease in the risk of hematoma expansion (RR = .8, 95% CI,.51-1.24; p = .31, I2 = 44%). It was also associated with a non-significant decrease in the risk of thrombotic events (RR,.83; 95% CI,.25-2.76; p = .76, I2 = 30%). However, patients in the DDAVP group demonstrated a significant increase in the risk of poor neurological outcomes (RR, 1.31; 95% CI, 1.07-1.61; p = .01, I2 = 0%). The risk of bias assessment showed a moderate to low level of risk. CONCLUSION DDAVP was associated with a nonsignificant decrease in hematoma expansion and thrombotic events. However, it was also associated with a significantly poor neurological outcome in the patients. Thus, until more robust clinical trials are conducted, the use of DDAVP should be considered on a case-to-case basis.
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Affiliation(s)
- Faizan Shahzad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Usman Ahmed
- Department of MedicineHoly Family HospitalRawalpindiPakistan
| | - Ayesha Muhammad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Farhan Shahzad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | | | | | | | - Sara Murtaza
- Department of MedicineHoly Family HospitalRawalpindiPakistan
| | | | - Haroon Shabbir
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Sajeel Saeed
- Department of MedicineHoly Family HospitalRawalpindiPakistan
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Fortunato M, Subah G, Thomas AD, Nolan B, Mureb M, Uddin A, Upadhyay K, Ogulnick JV, Damodara N, Bond C, Gandhi CD, Mayer SA, Al-Mufti F. Ultra-Early Hemostatic Therapy for Acute Intracerebral Hemorrhage: An Updated Review. Cardiol Rev 2024; 32:194-202. [PMID: 38517253 DOI: 10.1097/crd.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Intracerebral hemorrhage (ICH) is the second most common type of stroke, accounting for approximately 10-20% of all strokes, and is linked to severe neurological disability and death. Since the most accurate predictor of outcome in patients with ICH is hematoma volume, there is a great need for pharmacologic therapy that can reduce hematoma expansion and resultant mass effect and edema. This is especially critical within the ultra-early window of 3-4 hours after the presentation. Hemostatic therapies are exceptionally important for those patients taking antiplatelet or anticoagulant medications to reverse the effects of these medications and therefore prevent hematoma expansion. Furthermore, the recent publication of the 2023 Guideline for the Management of Patients with Aneurysmal Subarachnoid Hemorrhage by the American Heart Association/American Stroke Association, the first update to the guidelines since 2012, underscores the importance of optimizing anticoagulation reversal for this population. The purpose of this selective, nonsystematic review is to examine current literature regarding the use of hemostatic therapies in ICH, with particular attention paid to antiplatelet, anticoagulation, and antifibrinolytic therapies.
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Affiliation(s)
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Anish D Thomas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Monica Mureb
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Anaz Uddin
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kiran Upadhyay
- Department of Medicine, New York University Langone, Long Island, Mineola, NY
| | | | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Colleen Bond
- Department of Pharmacy, Westchester Medical Center, Valhalla, NY
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
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Jung IH, Yun JH, Kim SJ, Chung J, Lee SK. Anticoagulation and Antiplatelet Agent Resumption Timing following Traumatic Brain Injury. Korean J Neurotrauma 2023; 19:298-306. [PMID: 37840609 PMCID: PMC10567523 DOI: 10.13004/kjnt.2023.19.e42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/30/2023] [Accepted: 07/29/2023] [Indexed: 10/17/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health concern. Due to the increase in TBI incidence and the aging population, an increasing number of patients with TBI are taking antithrombotic agents for their underlying disease. When TBI occurs in patients with these diseases, there is a conflict between the disease, which requires an antithrombotic effect, and the neurosurgeon, who must minimize intracranial hemorrhage. Nevertheless, there are no clear guidelines for the reversal or resumption of antithrombotic agents when TBI occurs in patients taking antithrombotic agents. In this review article, we intend to classify antithrombotic agents and provide information on them. We also share previous studies on the reversal and resumption of antithrombotic agents in patients with TBI to help neurosurgeons in this dilemma.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sung Jin Kim
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jaewoo Chung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Koo Lee
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
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Summers A, Singh J, Lai M, Schomer KJ, Martin R, Vitt JR, Derry KL, Box K, Chu F, Arias V, Minokadeh A, Stern-Nezer S, Groysman L, Lee BJ, Atallah S. A multicenter retrospective study evaluating the impact of desmopressin on hematoma expansion in patients with antiplatelet-associated intracranial hemorrhage. Thromb Res 2023; 222:96-101. [PMID: 36610266 DOI: 10.1016/j.thromres.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Antiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts. MATERIALS AND METHODS Patients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 μg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition. RESULTS Among the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups. CONCLUSIONS These findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes.
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Affiliation(s)
- Amanda Summers
- Department of Pharmacy, University of California Irvine Health, 101 The City Dr S, Orange, CA 92868, USA
| | - Jasmeet Singh
- Department of Pharmacy, University of California Davis Health, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - Michelle Lai
- Department of Pharmacy, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Kendra J Schomer
- Department of Pharmacy, University of California Davis Health, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - Ryan Martin
- Department of Neurological Surgery and Neurology, University of California Davis Health, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - Jeffrey R Vitt
- Department of Neurological Surgery and Neurology, University of California Davis Health, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - Katrina L Derry
- Department of Pharmacy, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Kevin Box
- Department of Pharmacy, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Frank Chu
- Department of Pharmacy, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Valerie Arias
- Department of Neurosciences, Division of Neurocritical Care, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Anushirvan Minokadeh
- Department of Neurosciences, Division of Neurocritical Care, University of California San Diego Health, 200 W Arbor Dr, San Diego, CA 92103, USA
| | - Sara Stern-Nezer
- Department of Neurology, University of California, Irvine Health; 101 The City Dr S, Orange, CA 92868, USA
| | - Leonid Groysman
- Department of Neurology, University of California, Irvine Health; 101 The City Dr S, Orange, CA 92868, USA
| | - Benjamin J Lee
- Department of Pharmacy, University of California Irvine Health, 101 The City Dr S, Orange, CA 92868, USA
| | - Steven Atallah
- Department of Pharmacy, University of California Irvine Health, 101 The City Dr S, Orange, CA 92868, USA
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 333] [Impact Index Per Article: 166.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Gunther M, Witenko CJ, Prust M, Salerno D, Berger K. The Safety and Efficacy of Desmopressin in Patients With Intracranial Hemorrhage and a History of Alcohol Use. J Intensive Care Med 2021; 37:825-832. [PMID: 34286612 DOI: 10.1177/08850666211031494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with a history of alcohol use disorder are at an increased risk of hematoma expansion following intracranial hemorrhage (ICH) due to the effects of alcohol on platelet aggregation. Desmopressin (DDAVP) improves platelet aggregation and may decrease hematoma expansion in patients with ICH. However, DDAVP may also increase the risk of hyponatremia and thrombotic events. Evidence is limited regarding the safety and efficacy of DDAVP in alcohol use (AU)-associated ICH. METHODS This was a retrospective chart review of adult patients with radiographic evidence of ICH and a confirmed or suspected history of alcohol use upon admission. Patients were categorized into groups based on DDAVP administration. Safety outcomes included hyponatremia (serum sodium <135 mEq/L or decrease in serum sodium of ≥ 5 mEq/L for patients with baseline sodium <135 mEq/L) within 24 hours of ICH and thrombotic events within 7 days of ICH. The primary efficacy outcome was the incidence of hematoma expansion, defined as any expansion of the hemorrhage noted on repeat imaging within 32 hours. RESULTS In total, 52 patients were included in the safety analysis (27 DDAVP and 25 non-DDAVP). Although hyponatremia was numerically higher in the DDAVP group, there was no significant difference between groups (19.2% vs 4.2%, P = 0.192). Thrombotic complications were similar between the DDAVP and non-DDAVP groups (11.1% vs. 8%, P = 1.0). Thirty-nine patients met criteria for hemostatic efficacy analysis. There was no difference in hematoma expansion between the DDAVP and non-DDAVP groups (23.1% vs 34.6%, P = 0.71) and these findings were consistent after adjusting for differences in baseline characteristics (OR 0.63, 95% CI 0.1-3.3). CONCLUSION The administration of DDAVP was not associated with adverse safety events, but did not significantly reduce the incidence of hematoma expansion in patients with AU-associated ICH.
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Affiliation(s)
- Michelle Gunther
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Corey J Witenko
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Morgan Prust
- Department of Neurology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA. Gunther is now with Department of Pharmacy, The Hospital of Central Connecticut, New Britain, CT, USA
| | - David Salerno
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA.,Department of Neurology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA. Gunther is now with Department of Pharmacy, The Hospital of Central Connecticut, New Britain, CT, USA
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Baharoglu MI, Coutinho JM, Marquering HA, Majoie CB, Roos YB. Clinical Outcome in Patients With Intracerebral Hemorrhage Stratified by Type of Antithrombotic Therapy. Front Neurol 2021; 12:684476. [PMID: 34163431 PMCID: PMC8215162 DOI: 10.3389/fneur.2021.684476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Antithrombotic therapy influences clinical outcome after spontaneous intracerebral hemorrhage (ICH). However, evidence on the effect of different antithrombotic therapies on outcome and a comparison between different therapies is scarce, while this is important for medical decision making. Therefore, we investigated clinical outcome after ICH stratified by type of antithrombotic therapy. Patients/Methods: We performed a cohort study selecting consecutive ICH patients from our database, excluding patients without data on medication or therapeutic heparin use. Primary outcome was poor outcome (modified Rankin Scale ≥ 4) after 90 days. Secondary outcome was mortality at 90 days. We analyzed outcome and survival in patients with ICH using vitamin K antagonists (VKA), antiplatelet therapy (AP), and direct oral anticoagulant (DOAC) compared to no antithrombotic therapy adjusted for age, National Institutes of Health Stroke Scale (NIHSS), infratentorial localization, intraventricular extension, history of hypertension, diabetes, or stroke, and interaction between age and NIHSS. Results: We included 916 patients (223 AP, 161 VKA, and 40 DOAC). VKA (adjusted odds ratio [aOR] 3.2, 95% confidence interval [CI], 1.6–6.3) and AP (aOR = 2.0, 95%CI: 1.1–3.7) were associated with poor outcome. DOAC use did not reach statistical significance (aOR = 2.4, 95%CI: 0.8–7.7). Patients who used any antithrombotic therapy had poorer survival compared to patients without antithrombotic treatment and patients using AP and DOAC had better survival compared to VKA after adjustment. Conclusions: Patients with antithrombotic therapy have worse clinical outcome after ICH. Patients using VKA have higher risk of poor outcome and mortality compared to patients using AP. These findings highlight the deleterious effect of antithrombotic therapy in patients with ICH and stress the need for effective therapies for ICH patients.
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Affiliation(s)
- Merih Irem Baharoglu
- Department of Neurology, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands.,Biomedical Engineering and Physics, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands
| | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands
| | - Yvo B Roos
- Department of Neurology, Amsterdam University Medical Centers-Location Academic Medical Center, Amsterdam, Netherlands
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Early Administration of Desmopressin and Platelet Transfusion for Reducing Hematoma Expansion in Patients With Acute Antiplatelet Therapy Associated Intracerebral Hemorrhage. Crit Care Med 2021; 48:1009-1017. [PMID: 32304415 DOI: 10.1097/ccm.0000000000004348] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To investigate the hemostatic efficacy of combined desmopressin (1-deamino-8-D-arginine vasopressin) and platelet transfusion in reducing hematoma expansion in acute, spontaneous intracerebral hemorrhage under antiplatelet treatment. DESIGN Single-center, nonrandomized study, performed between 2006 and 2014. SETTING Tertiary University Hospital of Tuebingen, Germany. PATIENTS Adult patients with intracerebral hemorrhage under antiplatelet treatment and follow-up CT at 24 ± 12 hours were included. Exclusion criteria included other intracerebral hemorrhage causes, anticoagulation, coagulopathy, or immediate surgery after baseline-CT. INTERVENTIONS Treatment with IV 1-deamino-8-D-arginine vasopressin (0.4 µg/kg) + platelet transfusion (2 U) within 60 minutes of intracerebral hemorrhage under antiplatelet treatment diagnosis on brain imaging. MEASUREMENTS AND MAIN RESULTS Primary outcome was relative hematoma expansion from baseline to follow-up CT. Secondary outcomes included secondary intraventricular hemorrhage or hydrocephalus upon follow-up CT, thromboembolic events before discharge, and the 3-month functional outcome (assessed by modified Rankin Scale). One-hundred forty patients were included, 72 treated versus 68 controls. Times of symptom-onset-to-baseline-CT (hr) (median [interquartile range]: 3 [4] vs 5 [5]; p = 0.468) and follow-up CT (26 [18] vs 19 [12]; p = 0.352) were similar between groups. No between-group differences of total intracerebral hematoma expansion (%) (median [interquartile range]: 8.5 [12.4] vs 9.1 [16.5]; p = 0.825), intraparenchymal (10.7 [23.1] vs 9.2 [20.7]; p = 0.900), and intraventricular hematoma expansion (14.5 [63.2] vs 6.1 [40.4]; p = 0.304) were noted. Among patients with hematoma expansion greater than or equal to 33% compared with baseline, 16 (52%) received treatment versus 15 (48%) controls. The occurrence of hematoma expansion greater than or equal to 33% was similar between groups (p = 0.981). Rates of secondary intraventricular hemorrhage, hydrocephalus, and thromboembolic events were similar between groups. Treatment with 1-deamino-8-D-arginine vasopressin + platelet transfusion was not associated with the 3-month functional outcome (adjusted odds ratio, 1.570; 95% CI, 0.721-3.419; p = 0.309). CONCLUSIONS In line with the randomized Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Hemorrhage Associated With Antiplatelet Therapy trial, our results suggest no hemostatic efficacy of early platelet transfusion in intracerebral hemorrhage under antiplatelet treatment. Contrary to results of preclinical and clinical nonintracerebral hemorrhage studies, adjunct 1-deamino-8-D-arginine vasopressin showed no benefit in limiting hematoma expansion or improving functional outcome.
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10
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Desmopressin for Antiplatelet-Associated Intracranial Hemorrhage: A Concise Review. J Trauma Nurs 2021; 28:56-58. [PMID: 33417404 DOI: 10.1097/jtn.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a concise review of the literature on desmopressin use for antiplatelet reversal in patients with intracranial hemorrhage. DATA SOURCES Source data were obtained from a PubMed literature review. STUDY SELECTION Studies addressing desmopressin for antiplatelet reversal. DATA EXTRACTION Relevant studies were reviewed and included through consensus of the authors. The following aspects of each study were identified, abstracted, and analyzed: study population, study design, methods, results, and relevant implications for practice. DATA SYNTHESIS A growing body of evidence continues to provide mixed results for the use of desmopressin in patients presenting with antiplatelet-associated intracranial hemorrhage. The potential benefit outweighs the possible risks associated with a one-time dose. In addition to desmopressin, platelets should only be considered in patients undergoing a neurosurgical procedure until further and superior evidence is available. Guidelines recommend a weight-based approach for desmopressin dosing at 0.4 mcg/kg over 30 min. CONCLUSIONS The available evidence supports desmopressin as potentially beneficial with minimal risk for use in patients with antiplatelet-associated intracranial hemorrhage.
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for reversal of Antiplatelet drugs in Stroke due to Haemorrhage (DASH): protocol for a phase II double-blind randomised controlled feasibility trial. BMJ Open 2020; 10:e037555. [PMID: 33172941 PMCID: PMC7656949 DOI: 10.1136/bmjopen-2020-037555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/09/2020] [Accepted: 07/30/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Intracerebral haemorrhage (ICH) can be devastating and is a common cause of death and disability worldwide. Pre-ICH antiplatelet drug use is associated with a 27% relative increase in 1 month case fatality compared with patients not using antithrombotic drugs. We aim to assess the feasibility of conducting a randomised controlled testing the safety and efficacy of desmopressin for patients with antiplatelet-associated ICH. METHODS AND ANALYSIS We aim to include 50 patients within 24 hours of spontaneous ICH onset, associated with oral antiplatelet drug(s) use in at least the preceding 7 days. Patients will be randomised (1:1) to receive intravenous desmopressin 20 µg in 50 mL sodium chloride 0.9% infused over 20 min or matching placebo. We will mask participants, relatives and outcome assessors to treatment allocation. Feasibility outcomes include proportion of patients approached being randomised, number of patients receiving allocated treatment, rate of recruitment and adherence to treatment and follow-up. Secondary outcomes include change in ICH volume at 24 hours; hyponatraemia at 24 hours, length of hospital stay, discharge destination, early death less than 28 days, death or dependency at day 90, death up to day 90, serious adverse events (including thromboembolic events) up to day 90; disability (Barthel index, day 90), quality of life (EuroQol 5D (EQ-5D), day 90), cognition (telephone mini-mental state examination day 90) and health economic assessment (EQ-5D). ETHICS AND DISSEMINATION The Desmopressin for reversal of Antiplatelet drugs in Stroke due to Haemorrhage (DASH) trial received ethical approval from the East Midlands-Nottingham 2 research ethics committee (18/EM/0184). The DASH trial is funded by National Institute for Health and Care Research RfPB grant: PB-PG-0816-20011. Trial results will be published in a peer reviewed academic journal and disseminated through academic conferences and through patient stroke support groups. Reporting will be in compliance with Consolidated Standards of Reporting Trials recommendations. TRIAL REGISTRATION NUMBERS NCT03696121; ISRCTN67038373; EudraCT 2018-001904-12.
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Affiliation(s)
| | | | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Diane Havard
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottignham University Hospitals NHS Trust, Nottingham, UK
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Andersen LK, Hvas AM, Hvas CL. Effect of Desmopressin on Platelet Dysfunction During Antiplatelet Therapy: A Systematic Review. Neurocrit Care 2020; 34:1026-1046. [PMID: 32748210 DOI: 10.1007/s12028-020-01055-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE An increasing number of patients receive antiplatelet therapy. Patients exposed to surgery while receiving platelet inhibitors hold an increased bleeding risk. Especially in neurosurgery and neurocritical care patients, bleeding and hematoma expansion are feared complications as even minor bleedings may be hazardous. The objective of this systematic review was to investigate the effect of desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) on platelet function during antiplatelet therapy in patients undergoing non-cardiac surgery, patients who experience spontaneous or traumatic hemorrhage, healthy individuals and in animals. METHODS Studies were identified through a systematic literature search in PubMed and EMBASE on August 19, 2019, with an update on May 2, 2020, and from reference lists of the included studies. Data on clinical and biochemical effect of DDAVP were extracted from included studies for a qualitative data synthesis. RESULTS In total, 22 studies were included: 18 human studies and four animal studies. Overall, DDAVP improved bleeding time and increased platelet aggregation in patients undergoing non-cardiac surgery, patients suffering intracerebral or subarachnoid hemorrhage while receiving antiplatelet therapy as well as in healthy individuals and animals exposed to antiplatelet therapy. Observational data indicate that DDAVP may mitigate hematoma expansion in patients with intracerebral hemorrhage or traumatic brain injury. CONCLUSIONS The present data hold biochemical evidence that DDAVP improves platelet function during antiplatelet therapy in humans and animals. The need for randomized trials is evident in order to evaluate the potential clinical effect of DDAVP in management of patients with spontaneous or traumatic hemorrhage, or undergoing neurosurgery, while receiving antiplatelet therapy.
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Affiliation(s)
- Lise Kjær Andersen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.
| | - Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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