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Tallroth M, Udumyan R, Büki A, von Euler M. Antithrombotic Treatment and Clinical Outcomes After Intracerebral Hemorrhage: A Retrospective Cohort Study from the Swedish Stroke Register. J Am Heart Assoc 2024; 13:e034716. [PMID: 38726922 PMCID: PMC11179832 DOI: 10.1161/jaha.123.034716] [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: 02/13/2024] [Accepted: 04/15/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND A rapid shift has occurred from vitamin K antagonists toward direct oral anticoagulants, which have a lower risk of intracerebral hemorrhage (ICH). However, effects on clinical outcomes after ICH are understudied. We aimed to describe the prevalence of antithrombotic drugs and to study the prognosis among prestroke functionally independent Swedish patients with ICH. METHODS AND RESULTS We identified all patients diagnosed with nontraumatic ICH in 2017 to 2021 from the Swedish Stroke Register (n=13 155) and assessed death and functional outcome at 3 months after ICH in prestroke functionally independent patients (n=10 014). Functional outcome was estimated among 3-month survivors on the basis of self-reported activities of daily living scores. Risks of outcomes were estimated using Poisson regression. In 13 155 patients, 14.5% used direct oral anticoagulant, 10.1% vitamin K antagonists, and 21.6% antiplatelets at ICH onset. Among 10 014 pre-stroke activities of daily living-independent patients, oral anticoagulants and antiplatelets were associated with increased mortality risk (adjusted risk ratio, 1.27 [95% CI, 1.13-1.43]; P<0.001; and adjusted risk ratio, 1.23 [95% CI, 1.13-1.34]; P<0.001 respectively). Mortality risk did not statistically differ between antiplatelets and oral anticoagulants nor between direct oral anticoagulant and vitamin K antagonists. Among 5126 patients with nonmissing functional outcome (69.1% of survivors), antiplatelets (adjusted risk ratio, 1.06 [95% CI, 0.99-1.13]; P=0.100) and oral anticoagulants (adjusted risk ratio, 1.01 [95% CI, 0.92-1.12]; P=0.768) were not statistically significantly associated with functional dependence. CONCLUSIONS There was no statistically significant difference in mortality risk between direct oral anticoagulant and vitamin K antagonists in prestroke functionally independent patients (unadjusted for oral anticoagulant class indication). Furthermore, mortality risk in antiplatelet and oral anticoagulant users might differ less than previously suggested.
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Affiliation(s)
- Mattias Tallroth
- Department of Neurology and Rehabilitation, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Ruzan Udumyan
- Department of Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, Faculty of Medicine and Health Örebro University Örebro Sweden
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Goeldlin MB, Siepen BM, Mueller M, Volbers B, Z'Graggen W, Bervini D, Raabe A, Sprigg N, Fischer U, Seiffge DJ. Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis. Eur Stroke J 2022; 6:333-342. [PMID: 35342809 PMCID: PMC8948504 DOI: 10.1177/23969873211061975] [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: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
Aims We assessed the association of prior antiplatelet therapy (APT) at onset of intracerebral haemorrhage (ICH) with haematoma characteristics and outcome. Methods We performed a systematic review and meta-analysis of studies comparing ICH outcomes of patients on APT (APT-ICH) with patients not taking APT (non-APT-ICH). Primary outcomes were haematoma volume (mean difference and 95% CI), haematoma expansion (HE), in-hospital 3-month mortality rates and good functional outcome (modified Rankin Scale score 0-2). We provide odds ratios (ORs) from random effects models and subgroup analyses for haematoma expansion and short-term mortality rates. Results We included 23 of 1551 studies on 30,949 patients with APT-ICH and 62,018 with non-APT-ICH. Patients on APT were older (Δmean 6.27 years, 95% CI 5.44-7.10), had larger haematoma volume (Δmean 5.74 mL, 95% CI 1.93-9.54), higher short-term mortality rates (OR 1.44, 95% CI 1.14-1.82), 3-month mortality rates (OR 1.58, 95% CI 1.14-2.19) and lower probability of good functional outcome (OR 0.61, 95% CI 0.49-0.77). While there was no difference in HE in the overall analysis (OR 1.32, 95% CI 0.85-2.06), HE occurred more frequently when assessed within 24 h (OR 2.58, 95% CI 1.18-5.67). We found insufficient data for comparison of single versus dual APT-ICH. Heterogeneity was substantial amongst studies. Discussion APT is associated with larger baseline haematoma volume, early (<24 h) haematoma expansion, mortality rates and morbidity in patients with ICH. Data on differences in single and dual APT-ICH are scarce and warrant further investigation. New treatment options for APT-ICH are urgently needed.
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Affiliation(s)
- Martina B Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Bernhard M Siepen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Werner Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nikola Sprigg
- Stroke, Division of Clinical Neuroscience, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Wang K, Liu Q, Wu J, Cao Y, Wang S. The role of monitoring platelet function perioperatively and platelet transfusion for operated spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy: A case report. Int J Surg Case Rep 2021; 89:106589. [PMID: 34844198 PMCID: PMC8636801 DOI: 10.1016/j.ijscr.2021.106589] [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: 09/08/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance Spontaneous intracerebral hemorrhage (SICH) with long-term oral antiplatelet therapy (LOAPT) is known as a dilemma in balancing the risk of postoperative rebleeding and ischemic events because of confused coagulation function. We herein describe a report of perioperative management of spontaneous intracerebral hemorrhage patient on long-term oral antiplatelet therapy. Case presentation A 42-year-old male patient on long-term oral antiplatelet therapy presented with coma, and he was diagnosed with spontaneous intracerebral hemorrhage. Considering the patient's clinical condition, despite the thromboelastography suggested that the inhibition of platelet function was high preoperatively, an emergency craniectomy were underwent. After platelet transfusion during surgery and taking control of the clotting and platelet function postoperatively, the patient was stable without rebleeding and new ischemic events in perioperative period and recovered satisfactorily. Clinical discussion Rare studies have provided evidence for managing operated spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet therapy, and whether platelet transfusion is recommended was controversial. In this case, we presented monitoring and taking control of clotting and platelet function postoperatively would help in preventing rebleeding and ischemic events in such patients; moreover, platelet transfusion may quickly and safely reverse platelet dysfunction for emergency surgery. This case was the first to report platelet function and coagulation function management in spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy. Conclusion Monitoring and maintaining coagulation and platelet function perioperatively are essential to balance the risk of postoperative rebleeding and ischemic events. Spontaneous intracerebral hemorrhage with antiplatelet therapy is known as a dilemma in postoperative management. Antiplatelet therapy may not be the absolute contraindication for surgery in the severe spontaneous intracerebral hemorrhage. It is essential to monitor and take control of platelet function in postoperative patients with antiplatelet therapy.
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Affiliation(s)
- Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China.
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Wu Y, Zhang D, Chen H, Liu B, Zhou C. Effects of Prior Antiplatelet Therapy on Mortality, Functional Outcome, and Hematoma Expansion in Intracerebral Hemorrhage: An Updated Systematic Review and Meta-Analysis of Cohort Studies. Front Neurol 2021; 12:691357. [PMID: 34497575 PMCID: PMC8419415 DOI: 10.3389/fneur.2021.691357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/25/2021] [Indexed: 02/05/2023] Open
Abstract
Background and Objective: Antiplatelet therapy (APT) is widely used and believed to be associated with increased poor prognosis by promoting bleeding in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to determine whether prior APT is associated with mortality, functional outcome, and hematoma expansion in ICH patients. Methods: The PubMed, Embase, and Web of Science databases were searched for relevant published studies up to December 11, 2020. Univariate and multivariable adjusted odds ratios (ORs) were pooled using a random effects model. Cochran's chi-squared test (Cochran's Q), the I 2 statistic, and meta-regression analysis were used to evaluate the heterogeneity. Meta-regression models were developed to explore sources of heterogeneity. Funnel plots were used to detect publication bias. A trim-and-fill method was performed to identify possible asymmetry and assess the robustness of the conclusions. Results: Thirty-one studies fulfilled the inclusion criteria and exhibited a moderate risk of bias. Prior APT users with intracerebral hemorrhage (ICH) had a slightly increased mortality in both univariate analyses [odds ratio (OR) 1.39, 95% CI 1.24-1.56] and multivariable adjusted analyses (OR 1.41, 95% CI 1.21-1.64). The meta-regression indicated that for each additional day of assessment time, the adjusted OR for the mortality of APT patients decreased by 0.0089 (95% CI: -0.0164 to -0.0015; P = 0.0192) compared to that of non-APT patients. However, prior APT had no effects on poor function outcome (pooled univariate OR: 0.99, 95% CI 0.59-1.66; pooled multivariable adjusted OR: 0.93, 95% CI 0.87-1.07) or hematoma growth (pooled univariate OR: 1.23, 95% CI 0.40-3.74, pooled multivariable adjusted OR: 0.94, 95% CI 0.24-3.60). Conclusions: Prior APT was not associated with hematoma expansion or functional outcomes, but there was modestly increased mortality in prior APT patients. Higher mortality of prior APT patients was related to the strong influence of prior APT use on early mortality. Systematic Review Registration:PROSPERO Identifier [CRD42020215243].
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Affiliation(s)
- Yujie Wu
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Donghang Zhang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Hongyang Chen
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Zhou
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Budinčević H, Črnac Žuna P, Saleh C, Lange N, Piechowski-Jozwiak B, Bielen I, Demarin V. Antithrombotic therapy in patients with non-traumatic intracerebral haemorrhage and atrial fibrillation: A retrospective study. Heliyon 2020; 6:e03219. [PMID: 32042969 PMCID: PMC7002828 DOI: 10.1016/j.heliyon.2020.e03219] [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: 11/04/2018] [Revised: 10/01/2019] [Accepted: 01/10/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The aim of the study was to determine the outcome, prescribed therapy, and localization of non-traumatic intracerebral haemorrhage in patients with atrial fibrillation. PATIENTS AND METHODS This retrospective study enrolled patients with atrial fibrillation hospitalised for non-traumatic intracerebral haemorrhage from 2004 to 2013. We compared the patients according to previous antithrombotic therapy, demographics, previous CHADS2 score, comorbidities, the international normalised ration, localisation of intracerebral hamorrhage, stroke severity, prescribed antithrombotic therapy and outcome. RESULTS A total of 85 patients were enrolled and assigned to an AT+ group (n = 49; 14 on aspirin, 35 on warfarin) and an AT- group (n = 36; without antithrombotic therapy prior to hospitalisation). The latter had a lower proportion of known atrial fibrillation (90% vs 47%, P < 0.001). The mean INR was 2.6 ± 1.5. The in-hospital mortality rates in both groups were high: 43% in AT+ group and 47% in AT- group. There were no significant differences in any of the predefined comparisons. CONCLUSION Treating patients with intracerebral haemorrhage and atrial fibrillation is challenging due to higher mortality rates and issues regarding the use of antithrombotic treatment in stroke prevention. Based on our data, prior antithrombotic therapy was not associated with increased in-hospital mortality rates or poorer functional outcome at hospital discharge in comparison with no prior antithrombotic therapy.
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Affiliation(s)
- Hrvoje Budinčević
- Stroke and Intensive Care Unit, Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
- School of Medicine, University J. J. Strossmayer, Osijek, Croatia
| | - Petra Črnac Žuna
- Stroke and Intensive Care Unit, Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Christian Saleh
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Nicholas Lange
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Ivan Bielen
- Stroke and Intensive Care Unit, Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
- School of Medicine, University J. J. Strossmayer, Osijek, Croatia
| | - Vida Demarin
- International Institute for Brain Health, Zagreb, Croatia
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Arnone GD, Kumar P, Wonais MC, Esfahani DR, Campbell-Lee SA, Charbel FT, Amin-Hanjani S, Alaraj A, Seicean A, Mehta AI. Impact of Platelet Transfusion on Intracerebral Hemorrhage in Patients on Antiplatelet Therapy–An Analysis Based on Intracerebral Hemorrhage Score. World Neurosurg 2018; 111:e895-e904. [DOI: 10.1016/j.wneu.2018.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
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Teo KC, Lau GK, Mak RH, Leung HY, Chang RS, Tse MY, Lee R, Leung GK, Ho SL, Cheung RT, Siu DC, Chan KH. Antiplatelet Resumption after Antiplatelet-Related Intracerebral Hemorrhage: A Retrospective Hospital-Based Study. World Neurosurg 2017; 106:85-91. [DOI: 10.1016/j.wneu.2017.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
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Chang Y, Kim YJ, Song TJ. Management of Oral Anti-Thrombotic Agents Associated Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Leong LB, David TKP. Is Platelet Transfusion Effective in Patients Taking Antiplatelet Agents Who Suffer an Intracranial Hemorrhage? J Emerg Med 2015; 49:561-72. [DOI: 10.1016/j.jemermed.2015.02.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/14/2015] [Accepted: 02/21/2015] [Indexed: 12/20/2022]
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Okada T, Nakase T, Sasaki M, Ishikawa T. Do the antithrombotic therapy at the time of intracerebral hemorrhage influence clinical outcome? analysis between the difference of antiplatelet and anticoagulant agents and clinical course. J Stroke Cerebrovasc Dis 2014; 23:1781-8. [PMID: 24957306 DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND It is controversial whether taking antiplatelet agents (APs) or anticoagulant agents (ACs) could influence clinical outcome after intracerebral hemorrhage (ICH). METHODS We retrospectively investigated 557 ICH patients between September 2008 and August 2013. We reviewed patients' characteristics, hematoma volume, deterioration (hematoma expansion, surgical hematoma evacuation, or death), and clinical outcome in modified Rankin Scale. RESULTS A total of 397 were classified as neither AP nor AC ("Nothing"), 81 as single AP (44 as aspirin [ASA], 22 as clopidogrel or ticlopidine [CLP/TIC], 7 as cilostazol, 8 as dual antiplatelet therapy), 43 as single AC (40 as warfarin, 2 as rivaroxaban, 1 as dabigatran), and 36 as both AP and AC (AP + AC). The clinical outcome was worse in APs than in "Nothing" (P = .021). Among APs, CLP/TIC showed poorer clinical outcome than ASA (P = .020). Deterioration was observed more frequently in AC than in "Nothing" (P < .001) and the clinical outcome was also worse in AC than in "Nothing" (P < .001). AP + AC use resulted in deterioration more frequently than "Nothing" (P < .001) and in poorer outcome than in "Nothing" (P < .001). CONCLUSIONS The use of antithrombotic agents could be associated with the deterioration after admission and the poor clinical outcome. CLP/TIC use may affect the poor outcome compared with ASA use.
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Affiliation(s)
- Takeshi Okada
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels Akita, Akita, Japan.
| | - Taizen Nakase
- Department of Stroke Science, Research Institute for Brain and Blood Vessels Akita, Akita, Japan
| | - Masahiro Sasaki
- Department of Stroke Science, Research Institute for Brain and Blood Vessels Akita, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels Akita, Akita, Japan
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Zis P, Leivadeas P, Michas D, Kravaritis D, Angelidakis P, Tavernarakis A. Predicting 30-day case fatality of primary inoperable intracerebral hemorrhage based on findings at the emergency department. J Stroke Cerebrovasc Dis 2014; 23:1928-33. [PMID: 24784015 DOI: 10.1016/j.jstrokecerebrovasdis.2014.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Early survival of patients with intracerebral hemorrhage (ICH) depends on several factors, including the location and size of the hematoma and the level of consciousness on admission. The aim of our study was to estimate the case fatality of primary inoperable ICH 30 days after the event in our hospital and to identify clinical and laboratory characteristics, recordable at the Emergency Department (ED), which could predict death at 30 days. METHODS Clinical and laboratory data on all patients with primary ICH admitted to our hospital were retrospectively collected. RESULTS Between January 2011 and June 2013 191 patients with primary ICH were admitted to our hospital. The 30-day case fatality rate was estimated to be 31.9%, as 61 patients died within 30 days after the ICH. Five variables were independently associated with 30-day case fatality: each decreased point at the Glasgow Coma Scale (GCS) is associated with a 1.3-fold increase in the odds of death at 30 days; infratentorial location and intraventricular extension are associated with a 5.5-fold and a 4.7-fold increase in the odds of death at 30 days, respectively; each centimeter of the maximum diameter of the hematoma and each point increase of the international normalized ratio (INR) are associated with a 1.9-fold and a 3.5-fold increase in the odds of death at 30 days, respectively. CONCLUSIONS GCS score on admission, infratentorial location of the hematoma, intraventricular extension of the hematoma, INR on admission, and maximum diameter of the hematoma are the 5 variables that are independently associated with 30-day case fatality of primary inoperable ICH. EDICH is introduced as a new grading scale, which includes laboratory and clinical findings at the ED and has predicting value of the 30-day case fatality.
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Affiliation(s)
- Panagiotis Zis
- Department of Neurology, Evangelismos General Hospital, Athens, Greece.
| | - Pavlos Leivadeas
- Department of Neurology, Evangelismos General Hospital, Athens, Greece
| | - Dimitrios Michas
- Department of Neurology, Evangelismos General Hospital, Athens, Greece
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James RF, Palys V, Lomboy JR, Lamm JR, Simon SD. The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage. Neurosurg Focus 2013; 34:E6. [DOI: 10.3171/2013.2.focus1328] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
New anticoagulant and antiplatelet medications have been approved and are prescribed with increased frequency. Intracranial hemorrhage is associated with the use of these medications. Therefore, neurosurgeons need to be aware of these new medications, how they are different from their predecessors, and the strategies for the urgent reversal of their effects. Utilization of intraluminal stents by endovascular neurosurgeons has resulted in the need to have a thorough understanding of antiplatelet agents. Increased use of dabigatran, rivaroxaban, and apixaban as oral anticoagulants for the treatment of atrial fibrillation and acute deep venous thrombosis has increased despite the lack of known antidotes to these medications.
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Affiliation(s)
- Robert F. James
- 1Division of Neurosurgery, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina; and
| | - Viktoras Palys
- 2Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Jason R. Lomboy
- 1Division of Neurosurgery, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina; and
| | - J. Richard Lamm
- 1Division of Neurosurgery, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina; and
| | - Scott D. Simon
- 2Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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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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Yildiz OK, Arsava EM, Akpinar E, Topcuoglu MA. Previous antiplatelet use is associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2011; 21:760-6. [PMID: 21683617 DOI: 10.1016/j.jstrokecerebrovasdis.2011.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 04/07/2011] [Accepted: 04/09/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with intracerebral hemorrhage (ICH) often report the use of antiplatelet medications, even more commonly than the use of anticoagulants. The effect of antiplatelet drugs on the course of ICH is controversial. In this study, our aim was to determine the effects of previous antiplatelet therapy on admission hematoma volume and hematoma expansion in patients with spontaneous ICH. METHODS A consecutive series of patients with a diagnosis of ICH who underwent brain computed tomographic (CT) scans within 12 hours of symptom onset and a follow-up CT scan within 72 hours were included in the study. Hematoma volume was calculated by using the ABC/2 method on admission and follow-up images. Univariate and multivariate analyses were performed to determine the independent role of antiplatelet use on baseline hematoma volume and hematoma expansion (defined as an increase in hematoma volume >12.5 mL or 33% of the baseline ICH volume). RESULTS A total of 153 patients were included in the study. Fifty-two (34%) patients were using antiplatelet drugs at the time of symptom onset. Antiplatelet users tend to have a larger baseline hematoma volume; however, this difference failed to reach statistical significance (P = .17). Antiplatelet therapy was found to be a significant determinant of substantial hematoma expansion, both in univariate and multivariate analyses (P < .01). CONCLUSIONS Previous antiplatelet use significantly contributes to hematoma expansion in patients with ICH.
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Affiliation(s)
- Ozlem Kayim Yildiz
- Department of Neurology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
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Ducruet AF, Hickman ZL, Zacharia BE, Grobelny BT, DeRosa PA, Landes E, Lei S, Khandji J, Gutbrod S, Connolly ES. Impact of platelet transfusion on hematoma expansion in patients receiving antiplatelet agents before intracerebral hemorrhage. Neurol Res 2011; 32:706-10. [PMID: 20819399 DOI: 10.1179/174313209x459129] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Patients receiving antiplatelet medications are reported to be at increased risk for hematoma enlargement and worse clinical outcomes following intracerebral hemorrhage (ICH). While platelet transfusions are frequently administered to counteract qualitative platelet defects in the setting of ICH, conclusive evidence in support of this therapeutic strategy is lacking. In fact, platelet transfusions may be associated with adverse effects, and represent a finite resource. We sought to determine the clinical efficacy of platelet transfusion and its impact on systemic complications following ICH in a cohort of patients receiving antiplatelet medications. METHODS We retrospectively analysed the medical records of 66 patients admitted to our institution from June 2003 to July 2008 who suffered a primary ICH while receiving antiplatelet (acetylsalicylic acid and/or clopidogrel) therapy. The primary outcome was the rate of significant (>25% increase from admission) hematoma expansion in transfused (n=35) versus non-transfused (n=31) patients. Discharge modified-Rankin score (mRS) and the rates of systemic complications were also assessed. RESULTS There were no statistically significant differences in rates of hematoma expansion between cohorts, nor were there differences in demographic variables, systemic complications or discharge mRS. Subgroup analysis revealed that there was a higher rate of hematoma expansion in the clopidogrel cohort (p=0.034) than in the cohort of patients receiving aspirin alone. DISCUSSION This study suggests that platelet administration does not reduce the frequency of hematoma expansion in ICH patients receiving antiplatelet medications. This lack of efficacy may relate to transfusion timing, as a significant proportion of hematoma expansion occurs within 6 hours post-ictus. Additionally, the increased rates of hematoma expansion in the clopidogrel cohort may relate to its prolonged half-life. A larger, prospective study is warranted.
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Affiliation(s)
- Andrew F Ducruet
- Department of Neurological Surgery, Columbia University, New York, NY 10032, USA
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16
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de Gans K, de Haan RJ, Majoie CB, Koopman MM, Brand A, Dijkgraaf MG, Vermeulen M, Roos YB. PATCH: platelet transfusion in cerebral haemorrhage: study protocol for a multicentre, randomised, controlled trial. BMC Neurol 2010; 10:19. [PMID: 20298539 PMCID: PMC2851678 DOI: 10.1186/1471-2377-10-19] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 03/18/2010] [Indexed: 02/06/2023] Open
Abstract
Background Patients suffering from intracerebral haemorrhage have a poor prognosis, especially if they are using antiplatelet therapy. Currently, no effective acute treatment option for intracerebral haemorrhage exists. Limiting the early growth of intracerebral haemorrhage volume which continues the first hours after admission seems a promising strategy. Because intracerebral haemorrhage patients who are on antiplatelet therapy have been shown to be particularly at risk of early haematoma growth, platelet transfusion may have a beneficial effect. Methods/Design The primary objective is to investigate whether platelet transfusion improves outcome in intracerebral haemorrhage patients who are on antiplatelet treatment. The PATCH study is a prospective, randomised, multi-centre study with open treatment and blind endpoint evaluation. Patients will be randomised to receive platelet transfusion within six hours or standard care. The primary endpoint is functional health after three months. The main secondary endpoints are safety of platelet transfusion and the occurrence of haematoma growth. To detect an absolute poor outcome reduction of 20%, a total of 190 patients will be included. Discussion To our knowledge this is the first randomised controlled trial of platelet transfusion for an acute haemorrhagic disease. Trial registration The Netherlands National Trial Register (NTR1303)
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Affiliation(s)
- Koen de Gans
- Department of Neurology, Academic Medical Centre, H2-222, PO-box 22660 1100 DD Amsterdam, The Netherlands.
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Stead LG, Jain A, Bellolio MF, Odufuye AO, Dhillon RK, Manivannan V, Gilmore RM, Rabinstein AA, Chandra R, Serrano LA, Yerragondu N, Palamari B, Decker WW. Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome? Clin Neurol Neurosurg 2009; 112:275-81. [PMID: 20042270 DOI: 10.1016/j.clineuro.2009.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 11/11/2009] [Accepted: 12/02/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients. METHODS Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006. RESULTS The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome. CONCLUSIONS Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.
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Affiliation(s)
- Latha G Stead
- Department of Emergency Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
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Malmivaara K, Hernesniemi J, Salmenperä R, Ohman J, Roine RP, Siironen J. Survival and outcome of neurosurgical patients requiring ventilatory support after intensive care unit stay. Neurosurgery 2009; 65:530-7; discussion 537-8. [PMID: 19687698 DOI: 10.1227/01.neu.0000350861.97585.ce] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to analyze the clinical outcome of severely ill neurosurgical patients whose need for artificial life support was extended. We sought to determine whether these patients benefit from extended treatment both in life expectancy and quality of life. Furthermore, we evaluated the direct cost of the neurosurgical treatment. METHODS The study group comprised a consecutive series of 346 neurosurgical patients in poor condition who were discharged from the intensive care unit but still in need of artificial respiratory support. The patients had various neurosurgical diagnoses and were treated between 2000 and 2003 at the Department of Neurosurgery, Helsinki University Central Hospital. We followed the outcome of these patients by specially formatted questionnaires 6 months and 1, 2, and 5 years after treatment. Their health-related quality of life was evaluated with EuroQol EQ-5D; quality-adjusted life years (QALY) gained with the treatment and the costs of a QALY were calculated. RESULTS The median follow-up time was 5 years. The mortality rate was 27% at 30 days, 45% at 1 year, and 59% at 5 years after treatment. Of the patients, 20% had a good recovery (Glasgow Outcome Scale [GOS] scores 4 and 5), 18% had severe disability (GOS score 3), none was in a vegetative state (GOS score 2), 59% were dead (GOS score 1), and 3% were lost to follow-up. Of the survivors, 69% lived at home, 22% in a nursing home, 2% were in a hospital, and 7% were lost to follow-up. The median EQ-5D index value was lower than the median index value for the general population: 0.71 (25th percentile [Q1] 0.38 and 75th percentile [Q3] 0.85) versus 0.85 (Q1 0.73 and Q3 1.00). The median cost of the direct neurosurgical treatment per patient was 15,000 euros (25th percentile, 10,000 euros 75th percentile, 22,000 euros). Surviving patients gained a mean of 17 +/- 13 QALYs. The cost of 1 QALY was 2521 euros. CONCLUSION Prolonged intensive care unit and step-down unit treatment of critically ill neurosurgical patients seems to be clinically justified. Moreover, direct costs of neurosurgical treatment were reasonably low.
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Affiliation(s)
- Kirsi Malmivaara
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Creutzfeldt CJ, Becker KJ, Longstreth W, Tirschwell DL, Weinstein JR. Platelet Dysfunction in Intraparenchymal Hemorrhage. Stroke 2009; 40:e645; author reply e646. [DOI: 10.1161/strokeaha.109.561191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Kyra J. Becker
- Harborview Medical Center, University of Washington, Seattle, Wash
| | - W.T. Longstreth
- Harborview Medical Center, University of Washington, Seattle, Wash
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Prior antiplatelet therapy, platelet infusion therapy, and outcome after intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2009; 18:221-8. [PMID: 19426894 DOI: 10.1016/j.jstrokecerebrovasdis.2008.10.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 10/16/2008] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Recent studies examining the effect of prior antiplatelet therapy (APT) on outcome in patients with spontaneous intracerebral hemorrhage (ICH) have shown conflicting results. The effect of platelet infusion therapy (PIT) on outcome in patients with ICH taking APT is unknown. METHODS We reviewed records of patients with ICH admitted to a single hospital, excluding those with international normalized ratio greater than or equal to 1.5. Baseline characteristics were compared by APT status in all patients and by PIT status in the subgroup of patients on APT. We used multivariate analyses to generate propensity and prognostic scores for exposures (APT and PIT) and outcomes (favorable outcome and hospital death), respectively. We examined the associations between exposures and outcomes and adjusted these for propensity and/or prognostic scores. We then validated our findings with a sensitivity analysis. RESULTS Of 368 patients identified, 121 (31.3%) were taking APT, mostly aspirin. Patients on APT were older and more likely to have vascular comorbidities than those not. The APT group also had a higher initial Glasgow Coma Scale score at presentation. In analyses adjusted for both propensity and prognostic scores, APT was associated with a higher likelihood of hospital death (odds ratio [OR] 2.4; 95% confidence interval [CI] 1.1-5.6); PIT did not prevent hospital death (OR 1.2; 95% CI 0.3-5.5) or increase favorable outcome (OR 1.4; 95% CI 0.4-5.4). CONCLUSIONS In patients with ICH, APT is associated with an increased risk of hospital death. In the subgroup of patients on APT, PIT did not prevent death or improve outcome.
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Grysiewicz RA, Thomas K, Pandey DK. Epidemiology of ischemic and hemorrhagic stroke: incidence, prevalence, mortality, and risk factors. Neurol Clin 2009; 26:871-95, vii. [PMID: 19026895 DOI: 10.1016/j.ncl.2008.07.003] [Citation(s) in RCA: 267] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The epidemiology of ischemic and hemorrhagic stroke is an ongoing exploration to identify risk factors that continue to expand with the advent of technological advancements and preventative medical practices. Identification of risk factors that can or cannot be modified is a crucial step in determining stroke risk. Many of the modifiable risk factors are well established, and specific interventions to reduce stroke risk have been established. Some risk factors are less established, and intervention to reduce risk is yet to be determined by evidence-based medicine. Data from ongoing randomized clinical trials continue to enhance our ability to prevent a first stroke.
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Affiliation(s)
- Rebbeca A Grysiewicz
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, USA
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Naidech AM, Bernstein RA, Levasseur K, Bassin SL, Bendok BR, Batjer HH, Bleck TP, Alberts MJ. Platelet activity and outcome after intracerebral hemorrhage. Ann Neurol 2009; 65:352-6. [DOI: 10.1002/ana.21618] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sansing LH, Messe SR, Cucchiara BL, Cohen SN, Lyden PD, Kasner SE. Prior antiplatelet use does not affect hemorrhage growth or outcome after ICH. Neurology 2009; 72:1397-402. [PMID: 19129506 DOI: 10.1212/01.wnl.0000342709.31341.88] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine whether antiplatelet medication use at onset of intracerebral hemorrhage (ICH) is associated with hemorrhage growth and outcome after spontaneous ICH using a large, prospectively collected database from a recent clinical trial. METHODS The Cerebral Hemorrhage and NXY-059 Treatment trial was a randomized, placebo-controlled trial of NXY-059 after spontaneous ICH. We analyzed patients in the placebo arm, and correlated antiplatelet medication use at the time of ICH with initial ICH volumes, ICH growth in the first 72 hours, and modified Rankin Score at 90 days. Patients on oral anticoagulation were excluded. RESULTS There were 282 patients included in this analysis, including 70 (24.8%) who were taking antiplatelet medications at ICH onset. Use of antiplatelet medications at ICH onset had no association with the volume of ICH at presentation, growth of ICH at 72 hours, initial edema volume, or edema growth. In multivariable analysis, there was no association of use of antiplatelet medications with any hemorrhage expansion (relative risk [RR] 0.85 [upper limit of confidence interval (UCI) 1.03], p = 0.16), hemorrhage expansion greater than 33% (RR 0.77 [UCI 1.18], p = 0.32), or clinical outcome at 90 days (odds ratio 0.67, 95% confidence interval 0.39-1.14, p = 0.14). CONCLUSIONS Use of antiplatelet medications at intracerebral hemorrhage (ICH) onset is not associated with increased hemorrhage volumes, hemorrhage expansion, or clinical outcome at 90 days. These findings suggest that attempts to reverse antiplatelet medications after ICH may not be warranted.
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Affiliation(s)
- L H Sansing
- Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 W Gates, Philadelphia, PA 19104, USA.
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Testai FD, Aiyagari V. Acute Hemorrhagic Stroke Pathophysiology and Medical Interventions: Blood Pressure Control, Management of Anticoagulant-Associated Brain Hemorrhage and General Management Principles. Neurol Clin 2008; 26:963-85, viii-ix. [DOI: 10.1016/j.ncl.2008.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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