Higher risk of deep vein thrombosis after hemorrhagic stroke than after acute ischemic stroke

Implementation of early prophylaxis for deep-vein thrombosis in intracerebral hemorrhage patients: an observational study from the Chinese Stroke Center Alliance

BACKGROUND

There is substantial evidence to support the use of several methods for preventing deep-vein thrombosis (DVT) following intracerebral hemorrhage (ICH). However, the extent to which these measures are implemented in clinical practice and the factors influencing patients' receipt of preventive measures remain unclear. Therefore, we aimed to evaluate the rate of the early implementation of DVT prophylaxis and the factors associated with its success in patients with ICH.

METHODS

This study enrolled 49,950 patients with spontaneous ICH from the Chinese Stroke Center Alliance (CSCA) between August 2015 and July 2019. Early DVT prophylaxis implementation was defined as an intervention occurring within 48 h after admission. Univariate and multivariate logistic regression analyses were conducted to identify the rate and factors associated with the implementation of early prophylaxis for DVT in patients with ICH.

RESULTS

Among the 49,950 ICH patients, the rate of early DVT prophylaxis implementation was 49.9%, the rate of early mobilization implementation was 29.49%, and that of pharmacological prophylaxis was 2.02%. Factors associated with an increased likelihood of early DVT prophylaxis being administered in the multivariable model included receiving early rehabilitation therapy (odds ratio [OR], 2.531); admission to stroke unit (OR 2.231); admission to intensive care unit (OR 1.975); being located in central (OR 1.879) or eastern regions (OR 1.529); having a history of chronic obstructive pulmonary disease (OR 1.292), ischemic stroke (OR 1.245), coronary heart disease or myocardial infarction (OR 1.2); taking antihypertensive drugs (OR 1.136); and having a higher Glasgow Coma Scale (GCS) score (OR 1.045). Conversely, being male (OR 0.936), being hospitalized in tertiary hospitals (OR 0.778), and having a previous intracranial hemorrhage (OR 0.733) were associated with a lower likelihood of early DVT prophylaxis being administered in patients with ICH.

CONCLUSIONS

The implementation rate of early DVT prophylaxis among Chinese patients with ICH was subpar, with pharmacological prophylaxis showing the lowest prevalence. Various controllable factors exerted an impact on the implementation of early DVT prophylaxis in this population.

Association between higher systemic immune inflammation index (SII) and deep vein thrombosis (DVT) in patients with aneurysmal subarachnoid hemorrhage (aSAH) after endovascular treatment

Inflammation contributes to deep vein thrombosis (DVT) formation in patients with aSAH after endovascular treatment. The relationship between systemic immune-inflammatory index (SII) as an inflammatory marker and DVT formation remains unclear. Thus, this study aims to evaluate the association between SII and aSAH-associated DVT following endovascular treatment. We enrolled 562 consecutive patients with aSAH after endovascular treatment at three centers from January 2019 to September 2021. The endovascular treatments included simple coil embolization and stent-assisted coil embolization. Deep venous thrombosis (DVT) was assessed by Color Doppler ultrasonography (CDUS). Multivariate logistic regression analysis was used to establish the model. We assessed the association of the SII, neutrophil-to-lymphocyte ratio (NLR), the systemic inflammatory response index (SIRI), platelet-lymphocyte ratio (PLR), and DVT by using restricted cubic spline (RCS). ASAH-associated DVT was found in 136 (24.20%) patients. Based on the multiple logistic regression analysis, the correlation was found between aSAH-associated DVT and elevated SII (fourth quartile) (adjusted odds ratio = 8.20 [95% confidence interval, 3.76-17.92]; p < 0.001 [p for trend < 0.001]), elevated NLR (fourth quartile) (adjusted odds ratio = 6.94 [95% confidence interval, 3.24-14.89]; p < 0.001 [p for trend < 0.001]), elevated SIRI (fourth quartile) (adjusted odds ratio = 4.82 [95% confidence interval, 2.36-9.84]; p < 0.001 [p for trend < 0.001]), and elevated PLR (fourth quartile) (adjusted odds ratio = 5.49 [95% confidence interval, 2.61-11.57]; p < 0.001 [p for trend < 0.001]). The increased SII was correlated with the formation of aSAH-associated DVT after endovascular treatment.

A novel risk score to predict deep vein thrombosis after spontaneous intracerebral hemorrhage

Background and purpose

Studies showed that patients with hemorrhagic stroke are at a higher risk of developing deep vein thrombosis (DVT) than those with ischemic stroke. We aimed to develop a risk score (intracerebral hemorrhage-associated deep vein thrombosis score, ICH-DVT) for predicting in-hospital DVT after ICH.

Methods

The ICH-DVT was developed based on the Beijing Registration of Intracerebral Hemorrhage, in which eligible patients were randomly divided into derivation (60%) and internal validation cohorts (40%). External validation was performed using the iMCAS study (In-hospital Medical Complication after Acute Stroke). Independent predictors of in-hospital DVT after ICH were obtained using multivariable logistic regression, and β-coefficients were used to generate a scoring system of the ICH-DVT. The area under the receiver operating characteristic curve (AUROC) and the Hosmer–Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively.

Results

The overall in-hospital DVT after ICH was 6.3%, 6.0%, and 5.7% in the derivation (n = 1,309), internal validation (n = 655), and external validation (n = 314) cohorts, respectively. A 31-point ICH-DVT was developed from the set of independent predictors including age, hematoma volume, subarachnoid extension, pneumonia, gastrointestinal bleeding, and length of hospitalization. The ICH-DVT showed good discrimination (AUROC) in the derivation (0.81; 95%CI = 0.79–0.83), internal validation (0.83, 95%CI = 0.80–0.86), and external validation (0.88; 95%CI = 0.84–0.92) cohorts. The ICH-DVT was well calibrated (Hosmer–Lemeshow test) in the derivation (P = 0.53), internal validation (P = 0.38), and external validation (P = 0.06) cohorts.

Conclusion

The ICH-DVT is a valid grading scale for predicting in-hospital DVT after ICH. Further studies on the effect of the ICH-DVT on clinical outcomes after ICH are warranted.

Risk factors and predictors for venous thromboembolism in people with ischemic stroke: A systematic review

Identification of individuals with ischemic stroke at particularly high risk of venous thromboembolism (VTE) is crucial for targeted thromboprophylaxis. To guide clinical decision-making and development of risk prediction models, increased knowledge on risk factors and biomarkers is needed. Therefore, we set out to identify risk factors and predictors for VTE in people with ischemic stroke by conducting a systematic review of the literature. Medline and Embase were searched from January 1990 and onwards. Studies investigating demographic, clinical, and/or laboratory factors for stroke-related VTE were considered. Two reviewers screened all retrieved records, independently and in duplicate. Risk of bias assessments were guided by a structured framework (PROSPERO-ID: CRD42020176361). Of 4674 identified records, 26 studies were included. Twenty-six demographic, clinical, and laboratory factors associated with increased risk of stroke-related VTE after multivariable adjustments were identified. The following factors were reported by ≥2 studies: prior VTE, cancer, prestroke disability, leg weakness, increasing lesion volume of the brain infarct, infection, low Barthel Index, increasing length of hospital stay, biochemical indices of dehydration, as well as elevated levels of D-dimer, C-reactive protein, and homocysteine. The majority of the studies were of poor quality with moderate or high risk of bias. In conclusion, this systematic review informs on several potential risk factors and predictors for VTE in people with ischemic stroke. To improve risk stratification and guide development of risk prediction models, further confirmation is needed because there were few high-quality studies on each factor.

Cardiovascular Events After Intracerebral Hemorrhage

Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.

Brain to periphery in acute ischemic stroke: Mechanisms and clinical significance

The social and public health burdens of ischemic stroke have been increasing worldwide. In addition to focal brain damage, acute ischemic stroke (AIS) provokes systemic abnormalities across peripheral organs. AIS profoundly alters the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and immune system, which further yield deleterious organ-specific consequences. Poststroke systemic pathological alterations in turn considerably contribute to the progression of ischemic brain injury, which accounts for the substantial impact of systemic complications on stroke outcomes. This review provides a comprehensive and updated pathophysiological model elucidating the systemic effects of AIS. To address their clinical significance and inform stroke management, we also outline the resulting systemic complications at particular stages of AIS and highlight the mechanisms. Future therapeutic strategies should attempt to integrate the treatment of primary brain lesions with interventions for secondary systemic complications, and should be tailored to patient individualized characteristics to optimize stroke outcomes.

Venous Thromboembolism in ICU Patients with Intracerebral Hemorrhage: Risk Factors and the Prognosis After Anticoagulation Therapy

Purpose

Venous thromboembolism (VTE) is a common complication of intracerebral hemorrhage (ICH) patients in intensive care unit (ICU), but anticoagulation therapy of ICH patients with VTE remains controversial. We aim to explore the risk factors and prognosis of anticoagulation therapy in ICH patients with VTE.

Patients and Methods

Medical records of ICH patients were collected from the Medical Information Mart for Intensive Care III (MIMIC-III version 1.4) database. The risk factors and prognosis of anticoagulation therapy in ICH patients with VTE were assessed by multivariable logistic regression analysis and Kaplan–Meier survival analysis, respectively.

Results

A total of 848 ICH patients were included in our study, of whom 69 ICH patients with VTE were screened, including 58 patients with deep vein thrombosis (DVT), 12 patients with pulmonary embolism (PE), and 1 patient with DVT and PE. In the multivariable logistic regression analysis, malignancy (odds ratio (OR): 4.262, 95% confidence interval (CI): 2.263–8.027, P=0.000), pulmonary circulation disease (OR: 28.717, 95% CI: 9.566–86.208, P=0.000), coagulopathy (OR: 2.453, 95% CI: 1.098–5.483, P=0.029), age > 60 years old (OR: 2.138, 95% CI: 1.087–4.207, P=0.028) and hospitalization time > 16 days (OR: 2.548, 95% CI: 1.381–4.701, P=0.003) were independent risk factors for VTE in ICH patients. Kaplan–Meier survival analysis and log-rank test found that, compared to non-anticoagulation group, anticoagulation group had higher cumulative survival rates during hospitalization, 28-day, 3-month, 1-year, and 4-year after admission, respectively.

Conclusion

Malignancy, pulmonary circulation disease, coagulopathy, age >60 years old and hospitalization time >16 days were independent risk factors for VTE in ICH patients, and anticoagulation therapy for VTE in ICH patients may be safe and effective. These findings need to be verified by more high-quality and well-designed randomized controlled trials.

Incidence and Risk Factors of Lower-Extremity Deep Vein Thrombosis After Thrombolysis Among Patients with Acute Ischemic Stroke

Background

Deep vein thrombosis (DVT) is common among patients with stroke. However, the incidence of DVT in acute ischemic stroke patients treated with thrombolytic therapy and the risk factors associated with this condition are unknown.

Objective

This study aimed to investigate the incidence and risk factors of DVT after thrombolysis in patients with acute ischemic stroke.

Settings and Methods

We retrospectively reviewed the medical records of all patients with acute ischemic stroke who underwent ultrasonic examination after intravenous thrombolysis between April 2017 and December 2019 at the stroke center of the First Hospital of Jilin University, China. Color duplex ultrasound was used to diagnosis DVT in all patients within 72 h after intravenous thrombolysis. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for DVT.

Results

Overall, 474 patients were included in the study. Of these, 75 (15.8%) developed DVT (95% confidence interval 12.5–19.1). Older age was the risk factor that most significantly affected the development of DVT (p = 0.001). Compared to patients younger than 60 years old, those aged 60–69 years and ≥70 years had a higher risk of DVT, at rates of 2.201 (95% CI: 1.033–4.689; p < 0.05) and 4.241 (95% CI: 2.016–8.922; p < 0.001) times higher, respectively. Patients with higher triglyceride levels (odds ratio 0.545, 95% CI: 0.372–0.799, p = 0.002) and longer activated partial thromboplastin time (OR 0.927, 95% CI: 0.862–0.996, p = 0.040) were less likely to have DVT.

Conclusion

DVT is a common complication among patients undergoing intravenous thrombolysis after acute ischemic stroke. Advanced age may increase the occurrence of DVT to some extent. For these patients, safe antiplatelet therapy should be explored and implemented as soon as possible.

A nomogram based on easily obtainable parameters for distal deep venous thrombosis in patients after acute stroke

OBJECTIVES

To develop and validate a nomogram to predict the probability of distal deep venous thrombosis (DVT) within first 14 days of stroke onset in patients by using easily obtainable parameters.

METHODS

This is a retrospective study. The presence of distal DVT was evaluated using ultrasonography within the first 14 days. Data were randomly assigned to either a modelling data set or a validation data set. Univariable and multivariate logistic regression analysis was used to determine risk scores to predict distal DVT in the modelling data set, and nomogram and calibration curve were constructed by R project.

RESULTS

A total of 1620 patients with acute stroke were enrolled in the study. The multivariate analysis revealed that the old age, female gender, haemorrhagic stroke, coronary heart disease, lower limb weakness, a low serum albumin level, and a high D-dimer level are highly predictive of 14-day risk of distal DVT. The AUC of the nomogram to predict the 14-day risk of distal DVT was 0.785 (95% CI, 0.742-0.827) and 0.813 (0.766-0.860) for the modelling cohort and external validation cohort, respectively. Moreover, the calibration of the nomogram showed a nonsignificant Hosmer-Lemeshow test statistic in the modelling (P = 0.876) and validation (P = 0.802) sets. With respect to decision curve analyses, the nomogram exhibited preferable net benefit gains than the staging system across a wide range of threshold probabilities.

CONCLUSION

The established nomogram displayed a superior performance in terms of predictive accuracy, discrimination capability, and clinical utility, may be helpful for clinicians to identify high-risk groups of distal DVT.

Development and Validation of a Nomogram for Lower Extremity Deep Venous Thrombosis in Patients after Acute Stroke

OBJECTIVES

To develope and validate a nomogram to predict the probability of deep venous thrombosis (DVT) in patients after acute stroke during the first 14 days with clinical features and easily obtainable biochemical parameters.

METHODS

This is a single-center prospective cohort study. The potential predictive variables for DVT at baseline were collected, and the presence of DVT was evaluated using ultrasonography within the first 14 days. Data were randomly assigned to either a modeling data set or a validation data set. Univariable and Multivariate logistic regression analysis was used to develop risk scores to predict DVT in the modeling data set and the area under the receiver operating characteristic curve to validate the score in the test data set, and nomogram and calibration curve were constructed by R project.

RESULTS

A total of 1651 patients with acute stroke were enrolled in the study. The overall incidence of DVT after acute stroke within two weeks was 14.4%. Multivariable analysis detected older age (≥65 years),female gender, hemorrhagic stroke, malignancy, lower limb muscle strength<3 grade, Albumin<40 g·L^-1 and D-dimer>0.5 mg·L^-1 were highly predictive of 14-day risk of DVT. The AUC of the nomogram with these above-mentioned independent risk factors to predict the 14-day risk of DVT was 0.756 (95% CI, 0.712-0.812) and 0.811 (95%CI, 0.762-0.859) for the modeling cohort and external validation cohort, respectively. Moreover, the calibration of the nomogram showed a nonsignificant Hosmer-Lemeshow test statistic in the modeling (P = 0.250) and validation sets (P = 0.995). With respect to decision curve analyses, the nomogram exhibited preferable net benefit gains than the staging system across a wide range of threshold probabilities.

CONCLUSION

This nomogram had a good performance in predictive accuracy, discrimination capability, and clinical utility, which was helpful for clinicians to identify high-risk groups of DVT and formulate relevant prevention and treatment measures.

PREvention of VENous Thromboembolism in Hemorrhagic Stroke Patients - PREVENTIHS Study: A Randomized Controlled Trial and a Systematic Review and Meta-Analysis

BACKGROUND

In this randomized trial, currently utilized standard treatments were compared with enoxaparin for the prevention of venous thromboembolism (VTE) in patients with intracerebral hemorrhage (ICH).

METHODS

Enoxaparin (0.4 mg daily for 10 days) was started after 72 h from the onset of ICH. The primary outcome was symptomatic or asymptomatic deep venous thrombosis as assessed by ultrasound at the end of study treatment. The safety of enoxaparin was also assessed. We included the results of this study in a meta-analysis of all relevant studies comparing anticoagulants with standard treatments or placebo.

RESULTS

PREVENTIHS was prematurely stopped after the randomization of 73 patients, due to the low recruitment rate. The prevalence of any VTE at 10 days was 15.8% in the enoxaparin group and 20.0% in the control group (RR 0.79 [95% CI 0.29-2.12]); 2.6% of enoxaparin and 8.6% of standard therapy patients had severe bleedings (RR 0.31 [95% CI 0.03-2.82]). When these results were meta-analyzed with the results of the selected studies (4,609 patients; 194 from randomized trials), anticoagulants were associated with a nonsignificant reduction in any VTE (OR 0.81; 95% CI 0.43-1.51), in pulmonary embolism (OR 0.53; 95% CI, 0.17-1.60), and in mortality (OR 0.85; 95% CI 0.64-1.12) without increase in hematoma enlargement (OR 0.97; 95% CI, 0.31-3.04).

CONCLUSIONS

In patients with acute ICH, the use of anticoagulants to prevent VTE was safe but the overall level of evidence was low due to the low number of patients included in randomized clinical trials.

Impact of hospital-acquired complications in long-term clinical outcomes after subarachnoid hemorrhage

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) usually have prolonged hospitalizations due to the need to closely monitor their neurological status. Therefore, these patients have higher risk of experiencing hospital-acquired complications (HACs), which can complicate their clinical course and recovery. However, there is no evidence on the impact of HACs of long-term clinical outcomes. We aimed to identify if HACs are independent risk factors for poor clinical outcomes at 12-18 months of follow-up.

PATIENTS AND METHODS

Retrospective analysis of 323 patients with SAH diagnosis from 2013 until June 2018. We collected patient-related factors (age, sex, body mass index (BMI), ethnicity), comorbidities (hypertension, smoke status, diabetes, coronary heart diseases, prothrombotic diseases and hypercholesterolemia), clinical variables (Hunt-Hess grade, modified Fisher grade, treatment, delayed cerebral ischemia), aneurysm characteristics (location, size) and HACs (pneumonia, deep vein thrombosis (DVT), urinary tract infection (UTI), external ventricular drainage (EVD) infections, sepsis, hyponatremia and acute respiratory distress syndrome). Poor outcomes were defined as mRS ≥ 3.

RESULTS

204 patients were included in the primary analysis. 82 (40.2%) experienced one or more HACs during their hospital course. Patients that developed HACs have significantly increased ICU (12.1 ± 6.6 vs 24.3 ± 23.6, p < .001) and hospital (18.7 ± 14.2 vs 35.3 ± 26.3, p < .001) length of stays. Moreover, patients with HACs had significant higher rates of delayed cerebral ischemia, non-routine discharge and poor outcomes at 90 days. 177 patients had complete follow-ups at 12-18 months, HACs were independent risk factors for poor functional outcomes at 12-18 months after adjusting for demographic, comorbidities and clinical variables [OR = 3.205, 95% CI 1.231-8.347, p < 0.001].

CONCLUSIONS

HACs are an independent risk factor of sustaining poor clinical outcomes 12-18 months after a SAH. Furthermore, HACs are significantly related with the occurrence of DCI, with non-routine discharge and 90-day poor functional outcomes.