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Jin Y, Huang YH, Chen YP, Zhang YD, Li J, Yang KC, Ye X, Jin LH, Wu J, Yuan CZ, Gao F, Tong LS. Combined effect of cortical superficial siderosis and cerebral microbleed on short-term and long-term outcomes after intracerebral haemorrhage. Stroke Vasc Neurol 2024; 9:429-438. [PMID: 37949481 DOI: 10.1136/svn-2023-002439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
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.
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Affiliation(s)
- Yujia Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yu-Hui Huang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Yu-Ping Chen
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yao-Dan Zhang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Jiawen Li
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Kai-Cheng Yang
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xianghua Ye
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Hang Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Neurology, Tiantai People's Hospital of Zhejiang Province, Taizhou, China
| | | | - Feng Gao
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Sha Tong
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Wang X, Chen T, Zhou J, Qin Y. Racial and ethnic differences in restarting antiplatelet therapy in patients with primary intracranial hemorrhage: a systematic review and meta-analysis. BMC Neurol 2024; 24:280. [PMID: 39127615 DOI: 10.1186/s12883-024-03790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND There has long been clinical disagreement over the resumption of antiplatelet therapy in patients with primary intracranial hemorrhage (ICH). This meta-analysis aimed to systematically evaluate the efficacy and safety of restarting antiplatelet therapy after ICH among different races and ethnicities. METHODS All relevant medical studies involving adults with antiplatelet-associated ICH published in PubMed, The Cochrane Library and Chinese National Knowledge Infrastructure from inception to March 2024 were sourced. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects model to assess the strength of association between resumption of antiplatelet therapy and our outcomes.The review was not registered and the review protocol was not prepared. RESULTS Thirty-five studies were included, with 9758 ICH patients. Subgroup analysis revealed that restarting antiplatelet therapy was associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage in Asians[OR = 1.48, 95% CI (1.13-1.94), P = 0.004]; in Caucasians, on the contrary, reinitiation of antiplatelet therapy was not associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage [OR = 0.85, 95% CI (0.67-1.06), P = 0.149]. Reinitiation of antiplatelet therapy was associated with a significantly lower risk of cerebral infarction [OR = 0.61, 95% CI (0.39-0.96), P = 0.033]. Restarting antiplatelet therapy after cerebral hemorrhage was not associated with a higher incidence rate of mortality [OR = 0.79, 95% CI (0.57, 1.08), P = 0.138], myocardial infarction [OR = 2.40, 95%CI (0.53,10.79), P = 0.253], hemiparesis [OR = 0.38, 95%CI (0.03,4.81), P = 0.451], neurological deficit [OR = 0.86,95%CI(0.32,2.33),P = 0.766]. CONCLUSION Reinstitution of antiplatelet therapy after ICH was associated with a lower risk of thromboembolic complications.Resumption of antiplatelet therapy was not associated with a higher incidence of cerebral hemorrhage in Caucasians, but may be associated with a higher risk of cerebral hemorrhage recurrence in Asian populations.
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Affiliation(s)
- Xuechang Wang
- Department of Pharmacy, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Anning, Yunnan Province, 650302, China
| | - Ting Chen
- Department of Pharmacy, Yancheng No.1 People's Hospital, Yancheng, Jiangsu Province, 224000, China
| | - Junning Zhou
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, Shandong Province, 252037, China
| | - Yuan Qin
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan Province, 646000, China.
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Yang J, Jing J, Chen S, Liu X, Wang J, Pan C, Tang Z. Reversal and resumption of anticoagulants in patients with anticoagulant-associated intracerebral hemorrhage. Eur J Med Res 2024; 29:252. [PMID: 38659079 PMCID: PMC11044346 DOI: 10.1186/s40001-024-01816-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
The use of anticoagulants has become more frequent due to the progressive aging population and increased thromboembolic events. Consequently, the proportion of anticoagulant-associated intracerebral hemorrhage (AAICH) in stroke patients is gradually increasing. Compared with intracerebral hemorrhage (ICH) patients without coagulopathy, patients with AAICH may have larger hematomas, worse prognoses, and higher mortality. Given the need for anticoagulant reversal and resumption, the management of AAICH differs from that of conventional medical or surgical treatments for ICH, and it is more specific. Understanding the pharmacology of anticoagulants and identifying agents that can reverse their effects in the early stages are crucial for treating life-threatening AAICH. When patients transition beyond the acute phase and their vital signs stabilize, it is important to consider resuming anticoagulants at the right time to prevent the occurrence of further thromboembolism. However, the timing and strategy for reversing and resuming anticoagulants are still in a dilemma. Herein, we summarize the important clinical studies, reviews, and related guidelines published in the past few years that focus on the reversal and resumption of anticoagulants in AAICH patients to help implement decisive diagnosis and treatment strategies in the clinical setting.
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Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiahui Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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5
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Gennaro N, Ferroni E, Zorzi M, Denas G, Pengo V. ISCHEMIC STROKE AND MAJOR BLEEDING WHILE ON DIRECT ORAL ANTICOAGULANTS IN NAÏVE PATIENTS WITH ATRIAL FIBRILLATION: IMPACT OF RESUMPTION OR DISCONTINUATION OF ANTICOAGULANT TREATMENT. A population-based study. Int J Cardiol 2024; 394:131369. [PMID: 37722453 DOI: 10.1016/j.ijcard.2023.131369] [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: 04/12/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
AIMS We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, in patients experiencing an anticoagulation-related event (stroke or major bleeding), occurred during anticoagulation therapy for AF. METHODS AND RESULTS We performed a retrospective population-based analysis on linked claims data of patients resident in the Veneto Region, treated with DOACs for AF and discharged (2013-2020) from the hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after a 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, ischemic stroke (IS)intracranial haemorrhage (ICH), and other major bleeding events (MB) were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Overall, 1029 patients (mean age 77 years) were included in the final cohort: 23% experienced an IS, 18% an ICH, and 59% MB. Of these, 77% resumed anticoagulation. The cumulative incidence of events was significantly lower in patients resuming therapy. In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the risk of a cumulative event (HR 0.45, 95%CI 0.35-0.57, p < 0.01). Stratifying for the index event, among patients with IS (92% resumed therapy), we observed a risk reduction of 81%; in patients with ICH (64% resumed therapy), we observed a risk reduction of 64% and for patients with MB (76% resuming therapy), we observed a risk reduction of 49%. CONCLUSIONS In patients with AF who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.
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Affiliation(s)
- N Gennaro
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - E Ferroni
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - M Zorzi
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - G Denas
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy
| | - V Pengo
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy; Arianna Foundation on Anticoagulation. Bologna, Italy.
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Cai H, Chen G, Hu W, Jiang C. Anticoagulant in atrial fibrillation patients with prior intracranial haemorrhage: a meta-analysis. Heart 2023; 109:1594-1600. [PMID: 37321829 DOI: 10.1136/heartjnl-2023-322492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The benefit of resuming anticoagulation in atrial fibrillation (AF) patients with prior intracranial haemorrhage (ICH) and which anticoagulant to choose are controversial. SUMMARY OF REVIEW PubMed, Embase, Web of Science and the Cochrane Library were searched from their inception until 13 February 2022. Thirteen eligible articles (17 600 participants) were collected, including 11 real-world studies (n=17 296) and 2 randomised controlled trials (RCTs) (n=304). Compared with no anticoagulants, oral anticoagulation (OAC) was not associated with an increased risk of ICH recurrence (HR 0.85 (95% CI 0.57 to 1.25), p=0.41), but with a significantly increased risk of major bleeding (HR 1.66 (95% CI 1.20 to 2.30), p<0.01). Meanwhile, OAC was associated with a reduced risk of ischaemic stroke/systemic thromboembolism (IS/SE) (HR 0.54 (95% CI 0.42 to 0.70), p<0.01) and all-cause death (HR 0.38 (95% CI 0.28 to 0.52), p<0.01) compared with no anticoagulants. Furthermore, compared with warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with a significant reduction of ICH recurrence (HR 0.64 (95% CI 0.49 to 0.85), p<0.01), while the risk of IS/SE and all-cause mortality were comparable between warfarin and NOACs. CONCLUSIONS For patients with AF with prior ICH, OAC is associated with a significant reduction in IS/SE and all-cause mortality without increasing ICH recurrence, but may increase major bleeding risk. Compared with warfarin, NOACs had a better safety profile and comparable efficacy. Further larger RCTs are warranted to validate these findings.
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Affiliation(s)
- Huiya Cai
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guoquan Chen
- Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Wei Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chunjiao Jiang
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
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Gorman J, Candeloro M, Schulman S. Anticoagulant Management and Outcomes in Nontraumatic Intracranial Hemorrhage Complicated by Venous Thromboembolism: A Retrospective Chart Review. Thromb Haemost 2023; 123:966-975. [PMID: 37015326 DOI: 10.1055/a-2068-6464] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND There are limited data on anticoagulant management of acute venous thromboembolism (VTE) after spontaneous intracranial hemorrhage (ICH). METHODS We reviewed retrospectively all cases diagnosed with VTE during hospitalization for spontaneous ICH at our center during 15 years. Anticoagulation management outcomes were (1) timing after ICH of anticoagulant initiation for VTE treatment, (2) use of immediate therapeutic dosing or stepwise dose escalation, and (3) the proportion achieving therapeutic dose. Primary clinical effectiveness outcome was recurrent VTE. Primary safety outcome was expanding ICH. RESULTS We analyzed 103 cases with VTE after 11 days (median; interquartile range [IQR]: 7-22) from the diagnosis of ICH. Forty patients (39%) achieved therapeutic anticoagulation 21.5 days (median; IQR: 14-34 days) from the ICH. Of those, 14 (35%; 14% of total) received immediately therapeutic dose and 26 (65%; 25% of total) had stepwise escalation. Anticoagulation was more aggressive in patients with VTE >14 days after admission versus those with earlier VTE diagnosis. Twenty-two patients (21%) experienced recurrent/progressive VTE-less frequently among patients with treatment escalation within 7 days or with no escalation than with escalation >7 days from the VTE. There were 19 deaths 6 days (median; IQR: 3.5-15) after the index VTE, with significantly higher in-hospital mortality rate among patients without escalation in anticoagulation. CONCLUSION Prompt therapeutic anticoagulation for acute VTE seems safe when occurring more than 14 days after spontaneous ICH. For VTE occurring earlier, it might also be safe with therapeutic anticoagulation, but stepwise dose escalation to therapeutic within a 7-day period might be preferable.
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Affiliation(s)
- Johnathon Gorman
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton Ontario, Canada
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton Ontario, Canada
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Weimar C, Thomalla G, Sandalcioglu IE. [Intracerebral Hemorrhage]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023; 91:104-119. [PMID: 36917974 DOI: 10.1055/a-2000-3783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Intracerebral hemorrhage (ICB) causes approximately 12% of all strokes in Germany and 9-27% of all strokes worldwide 1 2. Epidemiological studies show a decrease in younger individuals mainly due to better antihypertensive management, but there is also an increase in incidence in older individuals due to cerebral amyloid angiopathy and increasing use of anticoagulants 3.
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Samuel S, Menchaca C, Gusdon AM. Timing of anticoagulation for venous thromboembolism after recent traumatic and vascular brain Injury. J Thromb Thrombolysis 2023; 55:289-296. [PMID: 36479671 DOI: 10.1007/s11239-022-02745-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
Currently, there is no consensus guideline for initiating anticoagulation in patients with a traumatic or vascular brain injury. Initiating anticoagulation for management of venous thromboembolism (VTE) can vary significantly from 72 hours to 30 weeks due to the risk of hemorrhagic complications. The purpose of this study is to compare clinical outcomes using modified Rankin Score (mRS) in a patient population with early (≤ 3 days) versus late (> 3 days) initiation of therapeutic anticoagulation from the time VTE was diagnosed. This retrospective study included patients with a traumatic or vascular brain injury who developed either deep vein thrombosis (DVT) or pulmonary embolism (PE). Use of anticoagulation prior to admission, diagnosis with VTE on admission, or patients with a non-brain injury were exclusion criteria. Secondary outcomes measured were all-cause mortality, length of stay, and reasons for early interruption of anticoagulation. Therapeutic anticoagulation was started early in 76 (74%) patients compared to late initiation in 27 (26%) patients. Baseline characteristics were similar between the two groups. The mRS score 0-3 versus 4-6 was similar in patients who received early anticoagulation versus those who received it later. However, there was a trend favoring better outcomes in the early group [mRS 4-6; 78% vs. 93%; p = 0.085] and in subgroup analysis of patients with VTE diagnosed 4-7 days [mRS 4-6; 26% vs. 56%; p = 0.006] compared to the late group. In univariate and multivariable logistic regression, only age was associated with a significant worse outcome (median, IQR) 36 years (24-50) vs. 58 years (44-65) OR 1.07 (1.03-1.12); p < 0.001. In this study, early initiation of anticoagulation did not worsen clinical outcomes.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, 77030, Houston, TX, USA.
| | - Carlton Menchaca
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, 77030, Houston, TX, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, The University of Texas McGovern Medical School at Houston, Houston, TX, USA
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Juan MCY, Patel P, Zerona N, Christie A, Fendrikova Mahlay N, McLennan G, Tefera L. Increased incidence of venous thromboembolism associated with inferior vena cava filter placement in patients diagnosed with isolated calf deep vein thrombosis after intracranial hemorrhage or intracranial operation. J Thromb Thrombolysis 2023; 55:297-303. [PMID: 36525155 DOI: 10.1007/s11239-022-02736-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
In this study, we sought to investigate the effectiveness of inferior vena cava (IVC) filter placement in reducing the incidence of venous thromboembolism (VTE) in patients diagnosed with isolated calf deep vein thrombosis (DVT) after an intracranial hemorrhage or intracranial operation. A retrospective chart review (January 2000-December 2019) was performed to identify patients diagnosed with calf DVT after intracranial hemorrhage or intracranial operation. A total of 100 patients met the study criteria and were divided into groups based on treatment: IVC filter placement (n = 22), prophylactic anticoagulation (n = 42), or imaging surveillance (n = 36). Treatment-related complications were identified, and differences between groups in the primary endpoint (VTE occurrence after DVT diagnosis) were assessed using logistic regression. VTE occurred in 15 patients after calf DVT diagnosis. The rate of VTE was higher in the IVC filter group (9/22; 41%) than in the anticoagulation (2/42; 5%; p = 0.002) and surveillance (4/36; 11%; p = 0.013) groups. These treatment effects remained significant after adjustments were made for baseline characteristics (IVC filter vs anticoagulation, p = 0.009; IVC filter vs surveillance, p = 0.019). There was a single occurrence of pulmonary embolism in the surveillance group (3%). A single case of IVC filter thrombus was identified; no anticoagulation-related complications were reported. The findings of this study do not support IVC filter placement as a primary and solitary treatment for isolated calf DVT occurring after intracranial hemorrhage or intracranial operation.
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Affiliation(s)
- Michael C Y Juan
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Priyesh Patel
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Natalia Fendrikova Mahlay
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gordon McLennan
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Leben Tefera
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Forfang E, Larsen KT, Salman RA, Bell SM, Wester P, Berge E, Wyller TB, Rønning OM. Antithrombotic treatment after intracerebral hemorrhage: Surveys among stroke physicians in Scandinavia and the United Kingdom. Health Sci Rep 2023; 6:e1059. [PMID: 36698713 PMCID: PMC9854165 DOI: 10.1002/hsr2.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
Background and Aims It is unclear whether patients with previous intracerebral hemorrhage (ICH) should receive antithrombotic treatment to prevent ischemic events. We assessed stroke physicians' opinions about this, and their views on randomizing patients in trials assessing this question. Methods We conducted three web-based surveys among stroke physicians in Scandinavia and the United Kingdom. Results Eighty-nine of 205 stroke physicians (43%) responded to the Scandinavian survey, 161 of 180 (89%) to the UK antiplatelet survey, and 153 of 289 (53%) to the UK anticoagulant survey. In Scandinavia, 19 (21%) stroke physicians were uncertain about antiplatelet treatment after ICH for ischemic stroke or transient ischemic attack (TIA) and 21 (24%) for prior myocardial infarction. In the United Kingdom, 116 (77%) were uncertain for ischemic stroke or TIA and 115 (717%) for ischemic heart disease. In Scandinavia, 32 (36%) were uncertain about anticoagulant treatment after ICH for atrial fibrillation, and 26 (29%) for recurrent deep vein thrombosis or pulmonary embolism. In the United Kingdom, 145 (95%) were uncertain about anticoagulants after ICH in at least some cases. In both regions combined, 191 of 250 (76%) would consider randomizing ICH survivors in a trial of starting versus avoiding antiplatelets, and 176 of 242 (73%) in a trial of starting versus avoiding anticoagulants. Conclusion Considerable proportions of stroke physicians in Scandinavia and the United Kingdom were uncertain about antithrombotic treatment after ICH. A clear majority would consider randomizing patients in trials assessing this question. These findings support the need for such trials.
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Affiliation(s)
- Elisabeth Forfang
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Kristin Tveitan Larsen
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | | | - Simon M. Bell
- Sheffield Institute for Translational NeuroscienceUniversity of SheffieldSheffieldUK
| | - Per Wester
- Department of Public Health and Clinical ScienceUniversity of UmeåUmeåSweden
- Department of Clinical ScienceKarolinska Institutet Danderyds HospitalStockholmSweden
| | - Eivind Berge
- Department of CardiologyOslo University HospitalOsloNorway
| | - Torgeir Bruun Wyller
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Ole Morten Rønning
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of NeurologyAkershus University HospitalNordbyhagenNorway
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13
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Peng TJ, Viscoli C, Khatri P, Wolfe SQ, Bhatt NR, Girotra T, Kamel H, Sheth KN. In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation. Drugs 2022; 82:965-977. [PMID: 35657478 DOI: 10.1007/s40265-022-01729-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/03/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA
| | - Catherine Viscoli
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nirav R Bhatt
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Tarun Girotra
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, 15 York Street LCI, 1003C, New Haven, CT, 06510, USA.
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14
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 379] [Impact Index Per Article: 189.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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15
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Nguyen T, Sharma M, Crooks P, Patel PV, Bonow RH, Creutzfeldt CJ, Wahlster S. Between scylla and charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage. Br J Neurosurg 2022; 36:251-257. [PMID: 35343356 DOI: 10.1080/02688697.2022.2054944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To assess the risk of hematoma expansion in patients with acute intracranial hemorrhage (ICH) requiring therapeutic anticoagulation for the treatment of venous thromboembolism. METHODS We retrospectively reviewed all patients at our institution between 2014 and 2019 who were therapeutically anticoagulated for venous thromboembolism within 4 weeks after ICH. We included subtypes of traumatic ICH and spontaneous intraparenchymal hemorrhage. Our main outcome was the incidence of hematoma expansion within 14 days from initiating therapeutic anticoagulation. Hematoma expansion was defined as (1) radiographically proven expansion leading to cessation of therapeutic anticoagulation or (2) death due to hematoma expansion. Secondary outcomes included mortality due to hematoma expansion and characteristics associated with hematoma expansion. RESULTS Fifty patients met inclusion criteria (mean age: 54 years, 80% male, 76% Caucasian); 24% had undergone a neurosurgical procedure prior to therapeutic anticoagulation. Median time from ICH to therapeutic anticoagulation initiation was 9.5 days (IQR 4-17), 40% received therapeutic anticoagulation in <7 days after ICH. Six patients (12%) developed hematoma expansion, of whom two (4%) died. While not statistically significant, patients with hematoma expansion tended to be older (57.8 vs. 53.5 years), were anticoagulated sooner (4 vs. 10 days), presented with lower GCS (50% vs. 39% with GCS <8), higher hematoma volume (50% vs. 42% >30 cc), and higher SDH diameter (16 mm vs. 8.35 mm). There was a trend towards greater risk of hematoma expansion for patients undergoing endoscopic ICH evacuation (16% vs. 2%, p = 0.09); patients with hematoma expansion were more likely to present with hydrocephalus (67% vs. 16%, p = 0.02). CONCLUSIONS Our study is among the first to explore characteristics associated with hematoma expansion in patients undergoing therapeutic anticoagulation after acute ICH. Larger studies in different ICH subtypes are needed to identify determinants of hematoma expansion in this high-acuity population.
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Affiliation(s)
- Thuhien Nguyen
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Patrick Crooks
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Robert H Bonow
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | | | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, WA, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.,Department of Neurosurgery, University of Washington, Seattle, WA, USA
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16
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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17
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Cai Q, Zhang X, Chen H. Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review. Thromb J 2021; 19:93. [PMID: 34838069 PMCID: PMC8626951 DOI: 10.1186/s12959-021-00345-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.
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Affiliation(s)
- Qiyan Cai
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Zhang
- Respiratory Disease Department, Xinqiao Hospital, Chongqing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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18
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Baang HY, Sheth KN. Stroke Prevention After Intracerebral Hemorrhage: Where Are We Now? Curr Cardiol Rep 2021; 23:162. [PMID: 34599375 DOI: 10.1007/s11886-021-01594-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Patients after intracerebral hemorrhage (ICH) are at high risk of both ischemic stroke and recurrent ICH, and stroke prevention after ICH is important to improve the long-term outcomes in this patient population. The objective of this article is to review the current guidelines on stroke prevention measures after ICH as well as the new findings and controversies for future guidance. RECENT FINDINGS Intensive blood pressure reduction might benefit ICH survivors significantly. Cholesterol levels and the risk of ICH have an inverse relationship, but statin therapy after ICH might be still beneficial. Anticoagulation in atrial fibrillation after ICH specifically with novel oral anticoagulants may be associated with better long-term outcomes. Left atrial appendage occlusion may be an alternative for stroke prevention in ICH survivors with atrial fibrillation for whom long-term anticoagulation therapy is contraindicated. While complete individualized risk assessment is imperative to prevent stroke after ICH, future research is required to address current controversies and knowledge gap in this topic.
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Affiliation(s)
- Hae Young Baang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine & Yale New Haven Hospital, 15 York Street, Building LLCI, 10thFloor Suite 1003, P.O. Box 20818, New Haven, CT, 06520, USA.
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine & Yale New Haven Hospital, 15 York Street, Building LLCI, 10thFloor Suite 1003, P.O. Box 20818, New Haven, CT, 06520, USA
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19
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Little DHW, Sutradhar R, Cerasuolo JO, Perez R, Douketis J, Holbrook A, Paterson JM, Gomes T, Siegal DM. Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding. CMAJ 2021; 193:E304-E309. [PMID: 33649169 PMCID: PMC8034308 DOI: 10.1503/cmaj.201433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND: Data on resuming oral anticoagulants (OACs) after bleeding are primarily from studies involving patients given warfarin, with few data on direct OACs (DOACs). We aimed to characterize prescribing patterns for OACs after OAC-related bleeding and compare the rates of bleeding, thrombosis and mortality in patients who resumed either type of OAC with those who did not. METHODS: We conducted a population-based cohort study of adults aged 66 years or older who were admitted to hospital for bleeding while receiving OACs from Apr. 1, 2012, to Mar. 31, 2017, using linked administrative health databases from Ontario. We used competing risk methods to calculate cause-specific adjusted hazard ratios (HRs) for thrombosis, bleeding and mortality with resumption of OACs adjusted as a time-varying covariate. We determined time to OAC resumption using the Kaplan–Meier method. RESULTS: We included 6793 patients with gastrointestinal (n = 4297, 63.3%), intracranial (n = 805, 11.9%) or other bleeding (n = 1691, 25.0%). At cohort entry, 3874 patients (57.0%) were prescribed warfarin and 2919 patients (43.0%) were prescribed a DOAC. The most common indication for OAC was atrial fibrillation (n = 5557, 81.8%), followed by venous thromboembolism (n = 1367, 20.1%). Oral anticoagulants were resumed in 4792 patients (70.5%) within 365 days of the index bleed. The median time to resumption was 46 (interquartile range 6–550) days. We found that resuming OAC was associated with reduced rates of thrombosis (adjusted HR 0.60, 95% confidence interval [CI] 0.50–0.72) and mortality (adjusted HR 0.54, 95% CI 0.48–0.60), and an increased rate of rebleeding (adjusted HR 1.88, 95% CI 1.64–2.17). INTERPRETATION: We found that resuming OAC is associated with a reduction in thrombosis and mortality but an increase in bleeding. Randomized controlled trials that evaluate the net benefit of strategies for resumption of OAC after a bleeding event are warranted.
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Affiliation(s)
- Derek H W Little
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Rinku Sutradhar
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Joshua O Cerasuolo
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Richard Perez
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - James Douketis
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Anne Holbrook
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - J Michael Paterson
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Deborah M Siegal
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont.
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20
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Xu K, Chan NC, Eikelboom JW. Strategies for the prevention and treatment of bleeding in patients treated with dabigatran: an update. Expert Opin Drug Metab Toxicol 2021; 17:1091-1102. [PMID: 34357838 DOI: 10.1080/17425255.2021.1965124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Although dabigatran is safer than vitamin K antagonists, bleeding still occurs. Bleeding is an important cause of short-term morbidity and rarely mortality and can also have long-term consequences that are often under-appreciated. After bleeding, patients often do not restart treatment or are poorly adherent, which is associated with increased thromboembolism and mortality. Consequently, we need strategies to prevent and treat bleeding in patients with atrial fibrillation treated with dabigatran. AREAS COVERED We review a) relevant dabigatran pharmacology, b) the burden and consequences of bleeding, c) how to identify patients at high risk of bleeding; and d) existing and novel approaches to prevent and treat bleeding in dabigatran-treated patients. EXPERT OPINION Concerns about the risk of bleeding associated with anticoagulant therapy and emerging evidence of increased risk of thromboembolism and mortality after bleeding highlight the need for improved approaches to prevention and treatment of bleeding. Future research priorities should focus on improving our ability to prevent bleeding by identifying modifiable risk factors and the development of safer agents. The current front runners include drugs that selectively target the contact pathway of coagulation (e.g. factor XI). Targeting upstream drivers of thrombosis (e.g. inflammation) could help to further reduce the risk of thromboembolism.
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Affiliation(s)
- Ke Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Noel C Chan
- Population Health Research Institute, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
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21
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Sarfo FS, Adamu S, Obese V, Agbenorku M, Opare-Addo PA, Ovbiagele B. Atherosclerotic event risk and risk reduction therapies among Ghanaian hemorrhagic stroke survivors. J Neurol Sci 2021; 424:117389. [PMID: 33773409 DOI: 10.1016/j.jns.2021.117389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) stroke constitute up to 40% of incident strokes in Africa. While ICH patients are at high risk for atherosclerotic events, the risk-benefit of anti-atherosclerotic therapies in this patient population is uncertain. PURPOSE To assess whether utility of statins and/or antithrombotic agents after surviving an ICH correlates with atherosclerotic risk of an observational cohort. METHODS We analyzed data in a stroke registry prospectively collected on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, including diagnosis of ICH, co-morbidities, and key atherosclerotic risk reduction therapies (statins and anti-platelet drugs). We computed ischemic vascular risk using the Framingham Risk Score (FRS) to classify patients into low, intermediate and high vascular risk. RESULTS Of 1101 stroke survivors seen during the period, 244 (22.2%) had ICH. Vascular risk profiles were low (n = 86; 35.2%), intermediate (n = 71; 29.1%) and high (n = 87; 35.7%). Utility of statin use was 76.7% (low risk), 84.5% (intermediate risk), and 87.4% (high risk), p = 0.16 while antiplatelet use trended with atherosclerotic risk being 9.3% (low risk), 25.4% (intermediate risk), and high risk (34.5%), p = 0.0004. Independent factors associated with statin use were hypertension (OR 8.80; 95% CI: 2.34-33.11) and cigarette smoking (OR 0.29; 95% CI: 0.09-0.89) while antiplatelet drug use was associated with age (OR 1.43; 95% CI: 1.06-1.92) and time from index stroke (OR: 1.02; 95% CI: 1.01-1.02). CONCLUSION Approximately two-thirds of ICH survivors in this African sample had intermediate to high risk of future atherosclerotic events. Clinical trials on the timing, safety, and efficacy of statins and antiplatelet drugs among ICH survivors could help better guide risk mitigation in this population.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | | | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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22
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65-74 yrs, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage (ICH) is the most feared and deadly complication.In patients who survive an ICH, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address ICH risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision-making.
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23
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Cheng B, Li J, Peng L, Wang Y, Sun L, He S, Wei J, Zhang S. Efficacy and safety of restarting antiplatelet therapy for patients with spontaneous intracranial haemorrhage: A systematic review and meta-analysis. J Clin Pharm Ther 2021; 46:957-965. [PMID: 33537999 DOI: 10.1111/jcpt.13377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The benefits and risks of restarting antiplatelet therapy (APT) for patients with spontaneous intracranial haemorrhage (ICH) remain controversial. This meta-analysis was performed to explore the efficacy and safety of restarting APT for these patients. METHODS We followed the recommended PRISMA guidelines for systematic reviews. Studies from PubMed, Embase, Web of Science, CNKI and the Cochrane Library were systematically retrieved from the inception of each database to 31 July 2020. We also manually retrieved studies of reference. RESULTS AND DISCUSSION In this study, seven cohort studies and one randomized controlled trial (RCT) with subjects were included. APT resumption after spontaneous ICH did not significantly increase the risk of major haemorrhagic events (HR 1.15; 95% CI: 0.70-1.89; p = .59). However, it did not significantly reduce the risk of a composite endpoint concerning occlusive/thromboembolic events (HR 0.98; 95% CI: 0.81-1.19; p = .83) and all-cause mortality (HR 0.93; 95% CI: 0.80-1.08; p = .35). WHAT IS NEW AND CONCLUSION Restarting APT for patients with spontaneous ICH is generally safe. However, the benefits of reducing the risk of ischaemic vascular events and all-cause mortality were not apparent. More RCTs are required.
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Affiliation(s)
- Bo Cheng
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jinze Li
- Department of Urology, People's Hospital of Deyang City, Deyang, China
| | - Lei Peng
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University, Nanchong, China
| | - Yirong Wang
- Department of Neurology, Chengdu Second People's Hospital, Chengdu, China
| | - Ling Sun
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Shijia He
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jing Wei
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Shushan Zhang
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
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24
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Low-dose antiplatelet therapy survey after intracerebral hemorrhage in China: a retrospective hospital-based study. Neurosurg Rev 2021; 44:2923-2931. [PMID: 33502641 DOI: 10.1007/s10143-021-01483-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/10/2020] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
Restarting of antiplatelet therapy (AT) for patients with a history of intracerebral hemorrhage (ICH) is still a clinical dilemma in China. We aimed to investigate the association between low-dose AT and the long-term clinical outcome in Chinese ICH patients. A total of 312 patients with a history of ICH were retrospectively enrolled and followed. The ischemic vascular events, recurrent ICH, and all-cause death were reviewed retrospectively. We explored the predictors of ischemic vascular events and recurrent ICH from all patients using Cox proportional hazard regression model. One hundred fifty-one (48.4%) patients were treated with low-dose AT, and the median duration of follow-up was 4.0 years (interquartile range, 2.5-5 years). Compared to 30 (19.8%) of 151 participants who restarted low-dose AT had ischemic vascular events, 51 (31.7%) of 161 participants who did not receive AT showed ischemic vascular events (p=0.025). Eighteen (11.9%) of 151 participants treated with low-dose AT had recurrent ICH and 21 (13.0%) of 161 in non-AT participants (p=0.830). Cox regression analysis also showed that diabetes mellitus was an independent risk factor for ischemic vascular events (p=0.029). Uncontrolled blood pressure (BP) was independently associated with the risk for both ischemic vascular events (p=0.025) and recurrent ICH (p=0.001). Atrial fibrillation (AF) was an independent risk factor for recurrent ICH among patients with a history of ICH (p=0.018). In a Chinese population of patients with predominantly deep, mild to moderate severity ICH, restarting of low-dose AT at a median of 6.2 months was associated with a lower risk of ischemic vascular events without increased risk of recurrent ICH.
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25
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Becattini C, Cimini LA, Carrier M. Challenging anticoagulation cases: A case of pulmonary embolism shortly after spontaneous brain bleeding. Thromb Res 2021; 200:41-47. [PMID: 33529872 DOI: 10.1016/j.thromres.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
Abstract
Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
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26
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Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
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Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
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27
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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28
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Poli D, Antonucci E, Vignini E, Martinese L, Testa S, Simioni P, Pengo V, Pignatelli P, Falanga A, Masciocco L, Barcellona D, Ciampa A, Chiarugi P, Paparo C, Ageno W, Palareti G. Anticoagulation resumption after intracranial hemorrhage in patients treated with VKA and DOACs. Eur J Intern Med 2020; 80:73-77. [PMID: 32522446 DOI: 10.1016/j.ejim.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is associated with severe prognosis and recurrent risk. This impacts on the decision to resume anticoagulation in atrial fibrillation (AF) or venous thromboembolism (VTE) patients. Purpose of our study is to evaluate the incidence rate of recurrent ICH in patients with AF or VTE resuming anticoagulation after a first ICH episode. METHODS We report data of two cohorts of AF or VTE after a first ICH. The Vitamin K antagonist (VKA) cohort (166 patients) derives from CHIRONE Study, the direct oral anticoagulant (DOAC) cohort (178 patients) derives from START2-Register RESULTS: The clinical characteristics of the two cohort are similar with the exception of more prevalence of history of previous stroke/TIA in DOAC patients with respect to VKA (p = 0.02) and serum creatinine levels>1.5 mg/dL in VKA patients with respect to DOAC(p = 0.0001). The index ICH was spontaneous in 66.4% and in 33.7% among DOAC and VKAs cohort respectively (p = 0.0001). During follow-up, 14 recurrent ICH were recorded; 9 (rate 2.5 × 100 patient-years) in VKA and 5 (rate 1.3 × 100 patient-years) in DOAC (Relative Risk 1.9; 95% CI 0.6-7.4; p = 0.2). The univariate logistic regression analysis showed that patients with recurrent ICH were more frequently males, hypertensive, with a history of previous Stroke/TIA and older than patients without recurrence. VKA patients showed a higher risk of recurrence with respect to DOAC patients (OR 1.9;95% CI 0.7-6.7). CONCLUSIONS A trend toward fewer ICH recurrences was detected among DOACs patients in comparison to the previously reported rate of patients on warfarin.
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Affiliation(s)
- Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy.
| | | | - Elisa Vignini
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Lucia Martinese
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Sophie Testa
- UO Laboratorio Analisi, Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Paolo Simioni
- UOSD Malattie Trombotiche ed Emorragiche, UOC Medicina Generale, AOU Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Università degli Studi di Padova, Padova, Italy
| | - Pasquale Pignatelli
- Centro Trombosi, Clinica Medica Policlinico Umberto I°, Università la Sapienza Roma, Italy
| | - Anna Falanga
- University Milan Bicocca, Dept. Medicine and Surgery, Monza and UOC SIMT, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lucilla Masciocco
- UOC Medicina Interna, Centro Controllo Coagulazione, Presidio Ospedaliero Lastaria, Lucera (Foggia), Italy
| | - Doris Barcellona
- Struttura Dipartimentale di Emostasi e Trombosi, AOU di Cagliari, Dipartimento di Scienze Mediche e Sanita' Pubblica, Universita' di Cagliari, Cagliari, Italy
| | | | - Paolo Chiarugi
- U.O. Analisi Chimico-Cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carmelo Paparo
- Patologia Clinica, Ospedale Maggiore Chieri (Torino), Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
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29
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Larsen KT, Forfang E, Pennlert J, Glader EL, Kruuse C, Wester P, Ihle-Hansen H, Carlsson M, Berge E, Al-Shahi Salman R, Bruun Wyller T, Rønning OM. STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage: Protocol for a randomised controlled trial. Eur Stroke J 2020; 5:414-422. [PMID: 33598560 PMCID: PMC7856578 DOI: 10.1177/2396987320954671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background and aims Many patients with prior intracerebral haemorrhage have indications for antithrombotic treatment with antiplatelet or anticoagulant drugs for prevention of ischaemic events, but it is uncertain whether such treatment is beneficial after intracerebral haemorrhage. STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage will assess (i) the effects of long-term antithrombotic treatment on the risk of recurrent intracerebral haemorrhage and occlusive vascular events after intracerebral haemorrhage and (ii) whether imaging findings, like cerebral microbleeds, modify these effects. Methods STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage is a multicentre, randomised controlled, open trial of starting versus avoiding antithrombotic treatment after non-traumatic intracerebral haemorrhage, in patients with an indication for antithrombotic treatment. Participants with vascular disease as an indication for antiplatelet treatment are randomly allocated to antiplatelet treatment or no antithrombotic treatment. Participants with atrial fibrillation as an indication for anticoagulant treatment are randomly allocated to anticoagulant treatment or no anticoagulant treatment. Cerebral CT or MRI is performed before randomisation. Duration of follow-up is at least two years. The primary outcome is recurrent intracerebral haemorrhage. Secondary outcomes include occlusive vascular events and death. Assessment of clinical outcomes is performed blinded to treatment allocation. Target recruitment is 500 participants. Trial status: Recruitment to STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage is on-going. On 30 April 2020, 44 participants had been enrolled in 31 participating hospitals. An individual patient–data meta-analysis is planned with similar randomised trials.
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Affiliation(s)
- Kristin Tveitan Larsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | | | - Johanna Pennlert
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Christina Kruuse
- Herlev Gentofte Hospital and University of Copenhagen, Herlev, Denmark
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden.,Department of Clinical Sciences, Karolinska Institute, Danderyds Hospital, Stockholm, Sweden
| | - Hege Ihle-Hansen
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maria Carlsson
- Department of Neurology, Nordland Hospital Trust, Bodø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eivind Berge
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Ole Morten Rønning
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
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30
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Rivera-Caravaca JM, Esteve-Pastor MA, Camelo-Castillo A, Ramírez-Macías I, Lip GYH, Roldán V, Marín F. Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy. Expert Opin Pharmacother 2020; 21:1867-1881. [PMID: 32658596 DOI: 10.1080/14656566.2020.1789099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Oral anticoagulants (OAC) reduce stroke/systemic embolism and mortality risks in atrial fibrillation (AF). However, there is an inherent bleeding risk with OAC, where intracranial hemorrhage (ICH) is the most feared, disabling, and lethal complication of this therapy. Therefore, the optimal management of OAC-associated ICH is not well defined despite multiple suggested strategies. AREAS COVERED In this review, the authors describe the severity and risk factors for OAC-associated ICH and the associated implications for using DOACs in AF patients. We also provide an overview of the management of OAC-associated ICH and treatment reversal strategies, including specific and nonspecific reversal agents as well as a comprehensive summary of the evidence about the resumption of DOAC and the optimal timing. EXPERT OPINION In the setting of an ICH, supportive care/measures are needed, and reversal of anticoagulation with specific agents (including administration of vitamin K, prothrombin complex concentrates, idarucizumab and andexanet alfa) should be considered. Most patients will likely benefit from restarting anticoagulation after an ICH and permanently withdrawn of OAC is associated with worse clinical outcomes. Although the timing of OAC resumption is still under debate, reintroduction after 4-8 weeks of the bleeding event may be possible, after a multidisciplinary approach to decision-making.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Universidad De Murcia, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca) , Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
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31
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Anticoagulation decisions in elderly patients with stroke. Rev Neurol (Paris) 2020; 176:692-700. [PMID: 32631675 DOI: 10.1016/j.neurol.2020.04.015] [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: 01/06/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/22/2022]
Abstract
Primary and secondary prevention of stroke is often a challenge in elderly patients due to the increase in both thrombotic and hemorrhagic risks with age. In some cases, there is sufficient data in the elderly population to allow recommendations or anticoagulation decisions to be made, such as for the indication of anticoagulation to prevent stroke related to atrial fibrillation (AF) or the choice of oral anticoagulant therapy in this situation. In other situations, the less robust data leave some questions; this is the case for the delay to initiate an oral anticoagulant therapy after an AF-related ischemic stroke, for the management of antithrombotic treatment after a stroke of undetermined cause or after intracranial bleeding or in a high-risk bleeding situation associated with stroke in the elderly subject. These issues will be discussed in this paper.
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32
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Sadighi A, Wasko L, DiCristina H, Wagner T, Wright K, Capone K, Monczewski M, Kester M, Bourdages G, Griessenauer C, Zand R. Long-term outcome of resuming anticoagulation after anticoagulation-associated intracerebral hemorrhage. eNeurologicalSci 2020; 18:100222. [PMID: 32123759 PMCID: PMC7037578 DOI: 10.1016/j.ensci.2020.100222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The risk and benefit of restarting oral anticoagulation (OAC) therapy among patients with atrial fibrillation or flutter (AF) and an episode of anticoagulation-associated intracerebral hemorrhage (ICH) remain unclear. Whether or not to resume OAC after an OAC-associated ICH will remain an unanswered clinical question until we have sufficient data through randomized clinical trials. Here, we analyzed the long-term outcome of patients with AF who did or did not resume OAC after an OAC-associated ICH. Patients and methods We studied consecutive patients with AF who were discharged from our institution after an OAC-associated ICH event between 2010 and 2017. Baseline characteristics of patients, past medical history, and history or OAC use were recorded. Outcome measures in our study included recurrent ICH, ischemic stroke or systemic emboli, and death. Results Out of 115 patients with AF and OAC-associated ICH, 93 patients (mean age 76.2 ± 10.3 years [44–91 years old], 54.3% men) were included in this study. Thirty-eight (40.9%) patients resumed OAC after the episode of OAC-associated ICH. More than 70% of patients had resumed OAC within two months of ICH (mean delay 56.0 ± 52.5 days). There was no significant difference between the group who resumed OAC and the group who did not in terms of mean follow-up duration (1.9 vs. 2.4 years), the type of initial ICH, as well as history of hypertension, diabetes, previous ischemic stroke, congestive heart failure, coronary artery disease, and tobacco use. There was no significant difference between the two groups considering the incidence rate of recurrent ICH (relative risk 2.9; 95% CI, 0.3–30.8). There was also no significant difference between the two groups regarding the incidence rate of ischemic stroke or systemic emboli (relative risk 0.9; 95% CI, 0.3–2.7). There was no significate difference between patients who did and did not resume OAC was 96 and 121 per 1000 patient-years, respectively (relative risk 0.8; 95% CI, 0.3–1.9). Conclusions We did not observe any significant difference between the group of patients who resumed OAC and the patients who did not in terms of recurrent ICH, ischemic stroke or systemic emboli, and death. However, there was a tendency toward a higher long-term risk of recurrent ICH among patients who resumed OAC. Outcome of AF patients who did/did not resume OAC after an OAC-ICH was studied. No significant difference between two groups in terms of recurrent ICH and death. Tendency toward a higher long-term risk of recurrent ICH in patients who resumed OAC.
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Affiliation(s)
- Alireza Sadighi
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Lisa Wasko
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Thomas Wagner
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Kathryn Wright
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Kellie Capone
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Margaret Kester
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - George Bourdages
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
- Corresponding author at: Department of Neurology, Division of Cerebrovascular Diseases, Geisinger Medical Center, 100 N Academy Ave, Danville, PA 17822, USA.
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Lee SR, Choi EK, Kwon S, Jung JH, Han KD, Cha MJ, Oh S, Lip GYH. Oral Anticoagulation in Asian Patients With Atrial Fibrillation and a History of Intracranial Hemorrhage. Stroke 2019; 51:416-423. [PMID: 31813363 DOI: 10.1161/strokeaha.119.028030] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and Purpose- Warfarin is associated with a better net clinical benefit compared with no treatment in patients with nonvalvular atrial fibrillation (AF) and history of intracranial hemorrhage (ICH). There are limited data on nonvitamin K antagonist oral anticoagulants (NOACs) in these patients, especially in the Asian population. We aimed to compare the effectiveness and safety of NOACs to warfarin in a large-scale nationwide Asian population with AF and a history of ICH. Methods- Using the Korean Health Insurance Review and Assessment database from January 2010 to April 2018, we identified patients with oral anticoagulant naïve nonvalvular AF with a prior spontaneous ICH. For the comparisons, warfarin and NOAC groups were balanced using propensity score weighting. Ischemic stroke, ICH, composite outcome (ischemic stroke+ICH), fatal ischemic stroke, fatal ICH, death from composite outcome, and all-cause death were evaluated as clinical outcomes. Results- Among 5712 patients with AF with prior ICH, 2434 were treated with warfarin and 3278 were treated with NOAC. Baseline characteristics were well-balanced after propensity score weighting (mean age 72.5 years and CHA2DS2-VASc score 4.0). Compared with warfarin, NOAC was associated with lower risks of ischemic stroke (hazard ratio [HR], 0.77 [95% CI, 0.61-0.97]), ICH (HR, 0.66 [95% CI, 0.47-0.92]), and composite outcome (HR, 0.73 [95% CI, 0.60-0.88]). NOAC was associated with lower risks of fatal stroke (HR, 0.54 [95% CI, 0.32-0.89]), death from composite outcome (HR, 0.53 [95% CI, 0.34-0.81]), and all-cause death (HR, 0.83 [95% CI, 0.69-0.99]) than warfarin. NOAC showed nonsignificant trends toward to reduce fatal ICH compared with warfarin (HR, 0.47 [95% CI, 0.20-1.03]). Conclusions- NOAC was associated with a significant lower risk of ICH and ischemic stroke compared with warfarin. NOAC might be a more effective and safer treatment option for Asian patients with nonvalvular AF and a prior history of ICH.
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Affiliation(s)
- So-Ryoung Lee
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.)
| | - Eue-Keun Choi
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.)
| | - Soonil Kwon
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.)
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Republic of Korea (J.-H.J., K.-D.H.)
| | - Kyung-Do Han
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Republic of Korea (J.-H.J., K.-D.H.)
| | - Myung-Jin Cha
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.)
| | - Seil Oh
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.)
| | - Gregory Y H Lip
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.).,Liverpool Centre for Cardiovascular Science, Liverpool Chest and Heart Hospital, University of Liverpool, United Kingdom (G.Y.H.L.).,Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.)
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Girotra T, Feng W. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): are neurologists feeling more comfortable to RESTART antiplatelet? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S214. [PMID: 31656793 DOI: 10.21037/atm.2019.08.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tarun Girotra
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Wuwei Feng
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
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Kozieł M, Ding WY, Kalarus Z, Lip GYH. Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding. Expert Rev Hematol 2019; 12:845-855. [PMID: 31334670 DOI: 10.1080/17474086.2019.1647779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction: Oral anticoagulants (OACs) are established treatments to reduce thromboembolic risk in patients with atrial fibrillation (AF). Due to their mechanisms of action, they are associated with increased bleeding risk. Evaluation with bleeding risk scores may be useful to identify patients at high risk. However, the approach in patients who have suffered a recent bleeding event while on OACs is a contentious issue. If a decision is made to re-initiate OACs, the optimal timing for this remains controversial. Areas covered: Bleeding risk scores were designed to evaluate risk in patients with AF and indications for OACs. Some practical schemes were created to manage bleeding in this population. The types of bleeding were classified as minor, major non-life-threatening and major life-threatening bleeding. In AF patients suffering from severe acute bleeding, it is recommended to withhold OACs until the underlying cause is identified and treated. Each case will require an individualized decision to restarting OAC therapy after consideration of the risks, benefits, alternatives and patient's choice in the matter. Expert opinion: Management of major bleeding and restarting OACs in patients with a recent major bleeding poses a special challenge due to high bleeding and thrombotic risk. This will be discussed in this review.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg , Denmark
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Ziai WC, Tsiskaridze A. Restarting antiplatelet therapy after intracerebral haemorrhage. Lancet 2019; 393:2567-2569. [PMID: 31128927 DOI: 10.1016/s0140-6736(19)31094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Wendy C Ziai
- Division of Brain Injury Outcomes, The Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Alexander Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
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Sembill JA, Kuramatsu JB, Hohnloser SH, Huttner HB. Management von intrazerebralen Blutungen unter oraler Antikoagulation. Herz 2019; 44:315-323. [DOI: 10.1007/s00059-019-4802-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sembill JA, Kuramatsu JB, Schwab S, Huttner HB. Resumption of oral anticoagulation after spontaneous intracerebral hemorrhage. Neurol Res Pract 2019; 1:12. [PMID: 33324878 PMCID: PMC7650131 DOI: 10.1186/s42466-019-0018-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023] Open
Abstract
Background Given an ageing population the incidence of both patients suffering from intracerebral hemorrhage (ICH) and those requiring oral anticoagulation will increase. Up to now there are no results from randomized trials available whether or not, and when, ICH survivors should resume OAC. This review summarizes the most important observational studies, and initiated ongoing trials, to help guiding physicians in daily routine decision making. Findings Several large observational studies and meta-analyses verified that OAC resumption was associated with a significant reduction of thromboembolic complications and mortality without leading to increased rates of recurrent ICH. OAC resumption seemed further associated with improved functional recovery and favorable long-term outcome. Given the general bleeding risk reduction in patients using Non–vitamin K antagonist oral anticoagulants (NOAC) compared to Vitamin-K-antagonist (VKA), NOAC use should also be preferred after ICH, although specific comparative studies are pending. Patients with lobar ICH need special attention as these patients showed increased ICH recurrence rates, why decision making should include extended diagnostic work-up evaluating cerebral microbleed burden, cortical subarachnoid hemorrhage and superficial siderosis. Further, patients with mechanical heart valves need specific consideration as restarting VKA may be unsafe until two weeks, whereas optimal balancing of hemorrhagic with thromboembolic complications may allow earlier re-initiation one week after ICH. In patients with atrial fibrillation, resumption generally should take place between 4 and 8 weeks after ICH depending on a patient’s individual risk profile. Left atrial appendage occlusion (LAAO) might represent an alternative strategy in high-risk patients. Ongoing clinical trials will clarify whether OAC resumption versus LAAO versus no antithrombotic therapy may represent the best possible secondary stroke prevention in ICH survivors with atrial fibrillation. Conclusions According to observational data OAC resumption after ICH seems beneficial and safe. Ongoing clinical trials will create evidence regarding treatment effects of pharmaceutical resumption and interventional alternatives. Yet, individual decision making weighing the patient’s individual thromboembolic versus hemorrhagic risks remains essential.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
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Kuramatsu JB, Huttner HB. Management of oral anticoagulation after intracerebral hemorrhage. Int J Stroke 2019; 14:238-246. [PMID: 30762497 DOI: 10.1177/1747493019828555] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The most recent years have significantly expanded knowledge regarding risks and benefits of resuming oral anticoagulation (OAC) after intracerebral hemorrhage (ICH). No randomized data is yet available, though several large observational studies and meta-analyses have investigated the impact of resuming OAC on thromboembolic versus hemorrhagic complications in these high-risk patients after ICH. AIMS The present review will summarize the most important studies conducted over the last years and will focus on relevant factors help guiding on decision-making on whether to start OAC after ICH. SUMMARY OF REVIEW Several important factors (demographic, co-morbidities, clinical characteristics) need to be considered before individual decision-making for or against OAC is employed. Existing observational data suggest that patients after ICH with indication for long-term oral anticoagulation benefit from OAC given significant reductions of thromboembolic events without significantly increasing bleeding complications. Studies even suggest that thereby also clinical outcomes may be improved. Prospective trials currently recruiting patients will clarify whether OAC after ICH - or left atrial appendage closure as a meaningful alternative - is of clinical net-benefit. CONCLUSIONS Large sized and well-executed investigations (moderate quality of evidence) are showing that OAC resumption after ICH decreases thromboembolic complications and long-term mortality without significantly increasing bleeding complications. Further, data suggest that resumption may be safer in non-lobar ICH compared to lobar ICH, but overall, thoughtful selection, strict blood pressure control, and precise communication are paramount before starting a patient on OAC after ICH.
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Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
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Sakamoto Y, Nito C, Nishiyama Y, Suda S, Matsumoto N, Aoki J, Shimoyama T, Kanamaru T, Suzuki K, Nishimura T, Mishina M, Kimura K. Safety of Anticoagulant Therapy Including Direct Oral Anticoagulants in Patients With Acute Spontaneous Intracerebral Hemorrhage. Circ J 2019; 83:441-446. [DOI: 10.1253/circj.cj-18-0938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuki Sakamoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Chikako Nito
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Yasuhiro Nishiyama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Satoshi Suda
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Noriko Matsumoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Junya Aoki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Takashi Shimoyama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Takuya Kanamaru
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Kentaro Suzuki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Takuya Nishimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
| | - Masahiro Mishina
- Department of Neuro-pathophysiological Imaging, Graduate School of Medicine, Nippon Medical School
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
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Previous chronic symptomatic and asymptomatic cerebral hemorrhage in patients with acute ischemic stroke. Neuroradiology 2018; 61:103-107. [PMID: 30488255 PMCID: PMC6336746 DOI: 10.1007/s00234-018-2141-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE Identifying previous chronic cerebral hemorrhage (PCH), especially asymptomatic cases in patients with ischemic stroke, is essential for proper antithrombotic management. The study aimed to further clarify the prevalence of PCH and the associated factors in patients with acute ischemic stroke using multi-modal neuroimaging including susceptibility-weighted MR imaging (SWI). METHODS This was a retrospective cross-sectional study of 382 patients with acute ischemic stroke. All patients underwent 3.0-T MRI for cranial SWI, 1.5-T or 3.0-T conventional cranial MRI, and cranial CT. Patients found with PCH were matched 1:4 with patients without PCH. Clinical manifestation, computed tomography, conventional cranial MRI, and cranial SWI were used to determine PCH. Clinical and neuroimaging findings between the patients with symptomatic vs. asymptomatic PCH were compared. RESULTS Thirty-six patients (36/382, 9.4%) were determined to have had a PCH. Of these 36 patients, 17 (17/36, 47.2%, or 17/382, 4.5%) had asymptomatic PCH. Multivariable analysis showed that serum total cholesterol (OR = 0.510, 95%CI 0.312-0.832, P = 0.007), cerebral microbleeds (OR = 6.251, 95%CI 2.220-17.601, P = 0.001), and antithrombotic drugs history (OR = 3.213, 95%CI 1.018-10.145, P = 0.047) were independently associated with PCH. Asymptomatic PCH had similar clinical and neuroimaging characteristics with symptomatic PCH. CONCLUSION PCH is not uncommon in acute ischemic stroke patients. Total serum cholesterol, cerebral microbleeds on SWI, and history of antithrombotic drugs were independently associated with PCH in patients with acute ischemic stroke. Asymptomatic PCH, which is easier to be missed and has similar characteristics with symptomatic PCH, should draw much attention.
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Abstract
Management of anticoagulation and antiplatelet medications after neurosurgery can be complex, especially given that these patients have multiple medical comorbidities. In turn, neurosurgical patients are at high risk for the development of venous thromboembolism after surgery, so neurosurgeons must consider the use of pharmacologic prophylaxis. Developments in endovascular neurosurgery have produced therapies that require close management of antiplatelet medications to prevent postoperative complications. Any of these patient populations may need intrathecal access. This article highlights current strategies for managing these issues in the neurosurgical patient population.
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Affiliation(s)
- Joel Z Passer
- Department of Neurosurgery, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA
| | - Christopher M Loftus
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA.
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Chen CJ, Ding D, Buell TJ, Testai FD, Koch S, Woo D, Worrall BB. Restarting antiplatelet therapy after spontaneous intracerebral hemorrhage: Functional outcomes. Neurology 2018; 91:e26-e36. [PMID: 29848784 DOI: 10.1212/wnl.0000000000005742] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 04/03/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the functional outcomes and health-related quality of life metrics of restarting vs not restarting antiplatelet therapy (APT) in patients presenting with intracerebral hemorrhage (ICH) in the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study. METHODS Adult patients aged 18 years and older who were on APT before ICH and were alive at hospital discharge were included. Patients were dichotomized based on whether or not APT was restarted after hospital discharge. The primary outcome was a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes were excellent outcome (modified Rankin Scale score 0-1), mortality, Barthel Index, and health status (EuroQol-5 dimensions [EQ-5D] and EQ-5D visual analog scale scores) at 90 days. RESULTS The APT and no APT cohorts comprised 127 and 732 patients, respectively. Restarting APT was associated with lower rates of good functional outcome (36.5% vs 40.8%; p = 0.021) and lower Barthel Index scores at 90 days (p = 0.041). The 2 cohorts were then matched in a 1:1 ratio, and the matched cohorts each comprised 107 patients. No difference in primary outcome was observed between restarting vs not restarting APT (35.5% vs 43.9%; p = 0.105). There were also no differences between the secondary outcomes of the 2 cohorts. CONCLUSION Restarting APT in patients with ICH of mild to moderate severity after acute hospitalization is not associated with worse functional outcomes or health-related quality of life at 90 days. In patients with significant cardiovascular risk factors who experience an ICH, restarting APT remains the decision of the treating practitioner.
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Affiliation(s)
- Ching-Jen Chen
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH.
| | - Dale Ding
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
| | - Thomas J Buell
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
| | - Fernando D Testai
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
| | - Sebastian Koch
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
| | - Daniel Woo
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
| | - Bradford B Worrall
- From the Departments of Neurological Surgery (C.-J.C., T.J.B.) and Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurosurgery (D.D.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (F.D.T.), University of Illinois, Chicago; Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL; and Department of Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati, OH
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Abstract
Purpose of review Decision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH. Recent findings OAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives. Summary Given the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.
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Zhou Z, Yu J, Carcel C, Delcourt C, Shan J, Lindley RI, Neal B, Anderson CS, Hackett ML. Resuming anticoagulants after anticoagulation-associated intracranial haemorrhage: systematic review and meta-analysis. BMJ Open 2018; 8:e019672. [PMID: 29764874 PMCID: PMC5961574 DOI: 10.1136/bmjopen-2017-019672] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To determine the adverse outcomes following resumption of anticoagulation in patients with anticoagulation-associated intracranial haemorrhage (ICH). DESIGN We performed a systematic review and meta-analysis in this clinical population. The Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement was followed, and two authors independently assessed eligibility of all retrieved studies and extracted data. DATA SOURCES Medline, Embase and the Cochrane Central Register of Controlled Trials, from inception to February 2017. ELIGIBILITY CRITERIA AND OUTCOMES Randomised controlled trials or cohort studies that recruited adults who received oral anticoagulants at the time of ICH occurrence and survived after the acute phase or hospitalisation were searched. Primary outcomes, including long-term mortality, recurrent ICH and thromboembolic events. Secondary outcomes were the frequency of resuming anticoagulant therapy and related factors. RESULTS We included 12 cohort studies (no clinical trials) involving 3431 ICH participants. The pooled frequency of resuming anticoagulant therapy was 38% (95% CI 32% to 44%), but this was higher in participants with prosthetic heart valves, subarachnoid haemorrhage or dyslipidaemia. There was no evidence that resuming anticoagulant therapy was associated with higher long-term mortality (pooled relative risk (RR) 0.60, 95% CI 0.30 to 1.19; p=0.14) or ICH recurrence (pooled RR 1.14, 95% CI 0.72 to 1.80; p=0.57). Resumption of anticoagulation was associated with significantly fewer thromboembolic events (pooled RR 0.31, 95% CI 0.23 to 0.42; p<0.001). In a subgroup of patients with atrial fibrillation, resuming anticoagulant therapy was associated with fewer long-term mortality (pooled RR 0.27, 95% CI 0.20 to 0.37, p<0.001). CONCLUSIONS Based on these observational studies, resuming anticoagulant therapy after anticoagulation-associated ICH has beneficial effects on long-term complications. Clinical trials are needed to substantiate these findings. PROSPERO REGISTRATION NUMBER CRD42017063827.
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Affiliation(s)
- Zien Zhou
- Department of Radiology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jiehui Shan
- Department of Geriatrics, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Richard I Lindley
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
- The George Institute China, Peking University Health Science Center, Beijing, China
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Hawkes MA, Rabinstein AA. Anticoagulation for atrial fibrillation after intracranial hemorrhage: A systematic review. Neurol Clin Pract 2018. [PMID: 29517050 DOI: 10.1212/cpj.0000000000000425] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We summarize the existing evidence on the potential benefit of oral anticoagulation (OAC) in intracerebral hemorrhage (ICH) survivors with nonvalvular atrial fibrillation (NVAF). Methods Systematic review of the literature to address the following issues: (1) prevalence of NVAF in ICH survivors, (2) current prescription of OAC, (3) factors associated with resumption of OAC, (4) risk of ischemic stroke (IS) and recurrent ICH, and (5) ideal timing for restarting OAC in ICH survivors with NVAF. Results After screening 547 articles, 26 were included in the review. Only 3 focused specifically on patients with ICH as primary event, NVAF as indication for OAC, and recurrent ICH and IS as primary endpoints. In addition, 19 letters to the editor/reviews/editorials/experts' surveys/experts' opinion were used for discussion purposes. Conclusions NVAF is highly prevalent among ICH survivors. The risks of IS, recurrent ICH, and mortality are heightened in this group. Most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted. However, those studies are observational and mostly retrospective, therefore selection bias may play a major role in the results observed in these cohorts. Only randomized controlled trials, either pragmatic or explanatory, can provide more conclusive answers for this important clinical question.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
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Scott M, Low R, Swan D, Thachil J. Reintroduction of anticoagulant therapy after intracranial haemorrhage: If and when? Blood Rev 2017; 32:256-263. [PMID: 29306488 DOI: 10.1016/j.blre.2017.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/30/2017] [Accepted: 12/19/2017] [Indexed: 01/08/2023]
Abstract
Intracranial haemorrhage is a devastating complication of anticoagulation. In surviving patients, physicians will be faced with the dilemma of if and when treatment should be reintroduced. There is little evidence to support this decision making and guidelines refrain from making specific recommendations. Existing data relates almost exclusively to vitamin K antagonists and is entirely retrospective. There appears to be an overall benefit to reintroducing anticoagulation in most patients; although, this may not be advocated in those at the highest risk of recurrent bleeding. The issue of when to reintroduce treatment is more controversial. The literature suggests timing could be anywhere between 7days and 30weeks; however there is no overall consensus. This review summarises what evidence is currently available to support decision making and suggests pragmatic management options based on a risk-benefit assessment of thromboembolism and recurrent bleeding; however, it should be acknowledged this may not be entirely evidence-based.
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Affiliation(s)
- Martin Scott
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
| | - Ryan Low
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
| | - Dawn Swan
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
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Chai-Adisaksopha C, Iorio A, Hillis C, Siegal D, Witt DM, Schulman S, Crowther M. Warfarin resumption following anticoagulant-associated intracranial hemorrhage: A systematic review and meta-analysis. Thromb Res 2017; 160:97-104. [DOI: 10.1016/j.thromres.2017.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/01/2017] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
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Ding X, Liu X, Tan C, Yin M, Wang T, Liu Y, Mo L, Wei X, Tan X, Deng F, Chen L. Resumption of antiplatelet therapy in patients with primary intracranial hemorrhage-benefits and risks: A meta-analysis of cohort studies. J Neurol Sci 2017; 384:133-138. [PMID: 29153510 DOI: 10.1016/j.jns.2017.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/18/2017] [Accepted: 11/08/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical disagreement over antiplatelet (AP) resumption in patients with primary intracranial hemorrhage (ICH) has long existed. This meta-analysis aimed to evaluate the benefits of AP resumption on preventing ischemic or thromboembolic events against its risks of promoting ICH recurrence or hematoma expansion. METHODS All relevant articles published in Pubmed, EMBASE, the Cochrane Library, and Science Direct from January 1950 to March 2017 were sourced, and the combined relative risk (RR) was calculated. RESULTS A total of 3648 articles were found, and after screening, 6 cohort studies including 1916 patients were included in this meta-analysis. AP resumption was associated with a decreased risk of ischemic or thromboembolic events (RR, 0.61; 95% confidence interval (CI), 0.48-0.79; P<0.01). There was no significant difference in the risk of ICH recurrence or hematoma expansion between patients with or without AP resumption (RR, 0.84; 95% CI, 0.47-1.51; P=0.56). CONCLUSION AP resumption in patients with primary ICH reduced the risk of ischemic or thromboembolic events, without significant increase of risk of ICH recurrence or hematoma expansion.
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Affiliation(s)
- Xueying Ding
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Changhong Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Maojia Yin
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Teng Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Lijuan Mo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Xin Wei
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Xinjie Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Fen Deng
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Lifen Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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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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