Early Administration of Desmopressin and Platelet Transfusion for Reducing Hematoma Expansion in Patients With Acute Antiplatelet Therapy Associated Intracerebral Hemorrhage

Advances and Future Trends in the Diagnosis and Management of Intracerebral Hemorrhage

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.

Potential clinical applications of current and future oral forms of desmopressin (Review)

Desmopressin is a synthetic analogue of vasopressin and a selective vasopressin receptor 2 agonist. It was first synthesised in 1967 and utilised for its antidiuretic properties. It is also used in bleeding disorders to enhance clotting. Other potential uses of the drug have been reported. The present review aims to provide a broad overview of the literature on potential further uses of oral forms of desmopressin. Key therapeutic areas of interest were identified based on known physiological activities/targets of desmopressin or reports of an effect of desmopressin in the literature. The feasibility of adequate dosing with oral forms of the drug was also considered. Systematic literature searches were carried out using the silvi.ai software for the identified areas, and summaries of available papers were included in tables and discussed. The results of the searches showed that desmopressin has been investigated for its efficacy in a number of areas, including bleeding control, renal colic, the central nervous system and oncology. Evidence suggests that oral desmopressin may have the potential to be of clinical benefit for renal colic and bleeding control in particular. However, further research is needed to clarify its effect in these areas, including randomised controlled studies and studies specifically of oral formulations (and doses). Further research may also yield findings for cancer, cognition and overactive bladder.

Emergent Management of Intracerebral Hemorrhage

OBJECTIVE

Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH.

LATEST DEVELOPMENTS

Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques.

ESSENTIAL POINTS

This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.

Safety and efficacy of desmopressin (DDAVP) in preventing hematoma expansion in intracranial hemorrhage associated with antiplatelet drugs use: A systematic review and metaanalysis

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.

Ultra-Early Hemostatic Therapy for Acute Intracerebral Hemorrhage: An Updated Review

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.

Combined effect of cortical superficial siderosis and cerebral microbleed on short-term and long-term outcomes after intracerebral haemorrhage

BACKGROUND AND PURPOSE

Cortical superficial siderosis (cSS) and cerebral microbleed (CMB) have distinct effects on intracerebral haemorrhage (ICH). We aim to investigate the combined effect of cSS and CMB on outcomes after ICH.

METHODS

Based on a single-centre stroke registry database, patients with spontaneous ICH who had CT scan within 48 hours after ictus and MRI subsequently were identified. Eligible patients were divided into four groups (cSS-CMB-, cSS-CMB+, cSS+CMB-, cSS+CMB+) according to cSS and CMB on susceptibility-weighted image of MRI. Primary outcomes were haematoma volume on admission and unfavourable outcome defined as modified Rankin Scale scores ≥3 at 3 months. Secondary outcomes were all-cause death, recurrence of stroke and ICH during follow-up (median follow-up 2.0 years, IQR 1.0-3.0 years).

RESULTS

A total of 673 patients were identified from 1044 patients with spontaneous ICH. 131 (19.5%) had cSS and 468 (69.5%) had CMB. Patients with cSS+CMB+ had the highest rate of poor outcome at 3 months, as well as all-cause death, recurrent stroke and ICH during follow-up. In cSS- patients, CMB was associated with smaller haematoma (β -0.13; 95% CI -0.22 to -0.03; p=0.009), but it still increased risks of recurrent ICH (OR 4.6; 95% CI 1.3 to 15.6; p=0.015) and stroke (OR 2.0; 95% CI 1.0 to 4.0; p=0.049). These effects of CMB became unremarkable in the context of cSS+.

CONCLUSIONS

Patients with different combinations of cSS and CMB have distinct patterns of short-term and long-term outcomes. Although CMB is related to restrained haematoma, it does not improve long-term outcomes.

TRIAL REGISTRATION NUMBER

NCT04803292.

Anticoagulation and Antiplatelet Agent Resumption Timing following Traumatic Brain Injury

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.

Therapeutic strategies for intracerebral hemorrhage

Stroke is the second highest cause of death globally, with an increasing incidence in developing countries. Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes. ICH is associated with poor neurological outcomes and high mortality due to the combination of primary and secondary injury. Fortunately, experimental therapies are available that may improve functional outcomes in patients with ICH. These therapies targeting secondary brain injury have attracted substantial attention in their translational potential. Here, we summarize recent advances in therapeutic strategies and directions for ICH and discuss the barriers and issues that need to be overcome to improve ICH prognosis.

Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage

Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.

Clinical Outcome in Patients With Intracerebral Hemorrhage Stratified by Type of Antithrombotic Therapy

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.

Effect of desmopressin on hematoma expansion in antiplatelet-associated intracerebral hemorrhage: A systematic review and meta-analysis

The purpose of this study was to perform a systematic review and meta-analysis on the effect of desmopressin on hematoma expansion (HE) in antiplatelet-associated intracerebral hemorrhage (AA-ICH). Secondary outcomes examined were the rate of thrombotic complications and neurologic outcome. Three databases were searched (Pubmed, Scopus, and Cochrane) for randomized clinical trials and controlled studies comparing desmopressin versus controls in adult patients with AA-ICH. The Mantel-Haenszel method was applied to calculate an overall effect estimate for each outcome by combining stratum-specific risk ratio (RR). Risk of bias was computed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (42020190234). Three retrospective controlled studies involving 263 patients were included in the meta-analysis. Compared to controls, desmopressin was associated with a non-significant reduction in HE (19.1% vs. 30%; RR:0.61; 95%CI, 0.27-1.39; P = 0.24), a similar rate of thrombotic events (5.5% vs. 9.9%; RR:0.47; 95%CI, 0.17-1.31; P = 0.15), and significantly worse neurologic outcome (mRS ≥ 4) (66.3% vs. 50%; RR:1.36; 95%CI, 1.08-1.7; P = 0.008). Qualitative analysis of included studies for each outcome revealed low to moderate risk of bias. The available literature does not support the routine use of desmopressin in the setting of AA-ICH. Until larger prospective trials are performed, the administration of desmopressin should be judiciously considered on a case-by-case basis.

Effect of Desmopressin on Platelet Dysfunction During Antiplatelet Therapy: A Systematic Review

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.

Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment

Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.