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Yuan JL, Xiao WK, Zhang CQ, Sun L, Lin YK, Hong CX. Incidence and characteristic of deep venous thrombosis in hospitalized chronic heart failure patients. Heart Vessels 2024; 39:597-604. [PMID: 38507055 DOI: 10.1007/s00380-024-02377-7] [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: 09/22/2023] [Accepted: 02/15/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND This study was conducted to investigate the incidence of deep venous thrombosis (DVT), outcomes and its characteristics in patients with chronic heart failure (CHF) in a retrospective setting. OUTCOMES Patients died of cardiac shock or acute exacerbation of heart failure (HF), admitted to intensive care unit (ICU) due to acute exacerbation of HF, patients decided to withdraw treatment and return home due to acute exacerbation of HF. METHODS From January 2015 to June 2022, we admitted 359 patients diagnosed with CHF, and lower limb ultrasonography was performed for the examination of DVT after admission. The incidence of DVT was recorded and patients with known risk factors of VTE were identified and excluded after incidence of DVT was calculated. Patients' clinical data were then collected. RESULTS The occurrence of DVT was 10.0% (36/359), as calf intramuscular vein thrombosis was the main constitution (n = 28, 75%). DVT patients with other factors (carcinoma, surgery, stroke, previous history of DVT) constituted a considerable part (33.3%, 12/36). Age, history of Diabetes Mellitus (DM), levels of DDi (D-Dimer), levels of alanine transferase (ALT) and left ventricular end-diastolic diameter (LVEDd) were independent predictors or risk factors of DVT in CHF patients, while chronic kidney disease (CKD) stage 1-4, white blood cell (WBC) and direct oral anticoagulant (DOAC) were protective factors. Incidence of DVT was correlated with a poor outcome of CHF patients (Pearson Chi-Square test, Value 19.612, P < 0.001). CONCLUSIONS In this retrospective study, incidence of DVT was found to be relatively high among hospitalized CHF patients, while patients with DVT was associated with a poor prognosis.
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Affiliation(s)
- Jia-Lin Yuan
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wen Kang Xiao
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Chao Qiong Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Le Sun
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Guangdong Province, Shenzhen, China
| | - Ying Kang Lin
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Chuang-Xiong Hong
- The Department of Cardiovascular Disease, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
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2
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Zhou Y, Wang G, Xue C, He G, Zhang Y, He F, He C, Liang X. Effect of heparin for the prevention of venous thromboembolism in patients with spontaneous intracranial cerebral hemorrhage: a meta-analysis. Ther Adv Drug Saf 2024; 15:20420986241253469. [PMID: 38784386 PMCID: PMC11113067 DOI: 10.1177/20420986241253469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
Background Venous thromboembolism (VTE) has a serious impact on the prognosis of patients with spontaneous intracranial hemorrhage (sICH). However, the use of prophylactic heparin remains controversial. Objectives This study investigated the safety and timing of prophylactic heparin for VTE in patients with sICH. Design This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Methods Two authors systematically searched Web of Science, Cochrane Library, Embase, and PubMed to find all published research before June 2023. The incidence of deep venous thrombosis (DVT) and mortality were set as primary endpoints. Results This meta-analysis included seven randomized controlled trials (RCTs) and five observational studies involving a total of 4419 sICH patients in the heparin (n = 2808) and control (n = 1183) groups. Among these patients, 205 received early heparin administration, while 223 received late heparin administration. The results suggested that, compared to the control group, patients in the heparin group had a lower incidence of VTE [odds ratio (OR), 0.47; 95% CI, 0.31-0.71; p < 0.001], DVT (OR, 0.53; 95% CI, 0.33-0.85; p = 0.009), pulmonary embolism (OR, 0.31 95% CI, 0.15-0.65; p = 0.002), and mortality (OR, 0.70; 95% CI, 0.54-0.90; p = 0.006), but there were no statistical differences in hematoma enlargement, extracranial hematoma, and major disability (p > 0.05). There was no statistically significant difference in DVT, mortality, hematoma enlargement, and extracranial hemorrhage between the early heparin group (<24-48 h) and the late heparin group (p > 0.05). Conclusion In patients with sICH, prophylactic use of heparin may be beneficial because it reduces the incidence of VTE and mortality without increasing the risk of additional bleeding. In addition, early prophylactic use of heparin appears to be safe. However, large-scale RCTs are lacking to support this evidence.
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Affiliation(s)
- Yifu Zhou
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Gang Wang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Chunxiao Xue
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Guojun He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Yan Zhang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Feilong He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Chenjun He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Xiaosong Liang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, No. 999, South Zhongxing Road, Shaoxing, Zhejiang 312000, China
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Maraziti G, Mosconi MG, Paciaroni M. Comparative study of venous thromboembolic prophylaxis strategies in hemorrhagic stroke: A systematic review and network meta-analysis. Int J Stroke 2024:17474930241248542. [PMID: 38591740 DOI: 10.1177/17474930241248542] [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: 04/10/2024]
Abstract
BACKGROUND Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage (ICH). Various prophylactic strategies have been employed to mitigate this risk, such as heparin, intermittent pneumatic compression (IPC), and graduated compression stockings (GCS). The optimal thromboembolic prophylaxis approach remains uncertain due to the lack of randomized controlled trials (RCTs) comparing all interventions. AIMS We conducted a network meta-analysis and meta-analysis to systematically review and synthesize evidence from RCTs and non-randomized studies on the efficacy and safety of thromboembolic prophylaxis strategies in hospitalized ICH patients. SUMMARY OF FINDINGS Our study followed a registered protocol (PROSPERO CRD42023489217) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines incorporating the extension for network meta-analyses. Search for eligible studies was performed up to December 2023. We considered the occurrence of DVT, PE, hematoma expansion (HE), and all-cause mortality as outcome measures. A total of 16 studies, including 7 RCTs and 9 non-randomized studies, were included in the analysis. Network meta-analysis revealed that IPC demonstrated the highest efficacy in reducing DVT incidence (odds ratios (OR) 0.30, 95% confidence interval (CI) 0.08-1.16), particularly considering only RCTs (OR 0.33, 95% CI 0.16-0.67). GCS showed the highest safety profile for HE (OR 0.67, 95% CI 0.14-3.13), but without efficacy. Chemoprophylaxis did not reduce the risk of PE events (OR 1.10, 95% CI 0.17-7.19) with a higher occurrence of HE (OR 1.33, 95% CI 0.60-2.96), but the differences were not significant. CONCLUSION Our study supports the use of IPC as the primary thromboembolic prophylaxis measure in ICH patients. Further research, including head-to-head RCTs, is needed to strengthen the evidence base and optimize clinical decision-making for thromboembolic prophylaxis in this vulnerable patient population.
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Affiliation(s)
- Giorgio Maraziti
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Maria Giulia Mosconi
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Jin J, Qiao S, Liu J, Li W, Wang F, Gao X, Tian J, Wang N, Zhang J, Dong J, li H, Wang J, Hu S, Zhou P. Neutrophil extracellular traps promote thrombogenicity in cerebral venous sinus thrombosis. Cell Biosci 2022; 12:114. [PMID: 35869501 PMCID: PMC9306243 DOI: 10.1186/s13578-022-00845-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Neutrophil extracellular traps (NETs) contribute to the creation of a coagulation state in various diseases. Currently, it is not clear whether NETs are present in the thrombi and plasma of patients with cerebral venous sinus thrombosis (CVST). This study aimed to investigate the presence of NETs in thrombi and blood samples from CVST patients and the procoagulant activity (PCA) of NETs during the progression of CVST. Results Thrombi obtained from CVST patients undergoing thrombectomy were examined by immunochemistry using neutrophil elastase (NE), CD66b and citrullinated histone H3(citH3). The presence of NET markers in samples from 37 CVST patients and 32 healthy people was evaluated by ELISA. NET-producing neutrophils and neutrophil-platelet (PLT) aggregates were examined in samples obtained from CVST patients and healthy people by flow cytometry. The TAT complex in plasma sample from each group was detected by ELISA to evaluate the procoagulant activity of NETs in CVST patients. Neutrophils from healthy subjects were treated with PLT-rich plasma in the presence of anti-PF4 antibodies or an autophagy inhibitor and analyzed by flow cytometry and confocal microscopy. After treatment with NETs, the expression of von Willebrand factor (VWF), tissue factor (TF) and CD31 in human brain microvascular endothelial cells (HBMECs) was measured by confocal microscopy and western blotting. Our results showed that NETs were abundant in the plasma and thrombi from CVST patients. Platelet factor 4 (PF4) from CVST PLTs induced NET generation through autophagy. NETs could induce PCA by modulating TF and phosphatidylserine (PS) in CVST. NETs also disrupted the endothelial barrier and transformed ECs into a procoagulant phenotype to exacerbate thrombogenicity. Conclusions NET generation was mediated by PF4 from PLTs through autophagy and contribute to thrombosis in CVST patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13578-022-00845-z.
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Jin J, Zhao X, Li W, Wang F, Tian J, Wang N, Gao X, Zhang J, Wu J, Mang G, Ma R, Hu S. Neutrophil extracellular traps: A novel therapeutic target for intracranial hemorrhage. Thromb Res 2022; 219:1-13. [DOI: 10.1016/j.thromres.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 10/31/2022]
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A Nomogram for Predicting Venous Thromboembolism in Critically Ill Patients with Primary Intracerebral Hemorrhage. World Neurosurg 2021; 157:e301-e307. [PMID: 34648989 DOI: 10.1016/j.wneu.2021.10.071] [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: 08/02/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To develop and validate a nomogram for predicting the risk of venous thromboembolism in critically ill patients with primary intracerebral hemorrhage. METHODS Patients ≥18 years old with primary intracerebral hemorrhage were screened within 24 hours of onset from January 2019 to April 2021. Univariate and multivariate logistic regression analyses were performed to screen out independent predictors that were significantly associated with venous thromboembolism. A nomogram was constructed based on the results of a multivariate regression analysis. Discrimination and calibration were used to evaluate performance of the nomogram. A decision curve analysis was used to assess its clinical utility. RESULTS This study enrolled 369 patients. The nomogram included 3 predictors from the regression analysis: D-dimer, National Institutes of Health Stroke Scale score, and Glasgow Coma Scale score on admission. The area under the receiver operating characteristic curve was 0.794, indicating good discrimination of the nomogram. The nomogram demonstrated calibration curves with slight deviation from the ideal predictions. Decision curve analysis showed that the prediction nomogram was clinically useful. CONCLUSIONS This nomogram comprising D-dimer, National Institutes of Health Stroke Scale score and Glasgow Coma Scale score on admission can accurately predict the risk of venous thromboembolism in critically ill patients with intracerebral hemorrhage.
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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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8
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Kananeh MF, Fonseca-Paricio MJ, Liang JW, Sullivan LT, Sharma K, Shah SO, Vibbert MD. Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH). J Stroke Cerebrovasc Dis 2020; 30:105476. [PMID: 33253987 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105476] [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] [Received: 08/28/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). BACKGROUND Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. METHODS We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality. RESULTS A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. CONCLUSION Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.
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Affiliation(s)
- Mohammed F Kananeh
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | | | - John W Liang
- Mount Sinai Heath System, Department of Neurosurgery & Neurology, New York, New York, USA
| | - Lindsay T Sullivan
- Novant Health Forsyth Medical Center, Department of Neurology, Winston-Salem, North Carolina, USA
| | - Kumud Sharma
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | - Syed Omar Shah
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA.
| | - Matthew D Vibbert
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
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Ji R, Li G, Zhang R, Hou H, Zhao X, Wang Y. Higher risk of deep vein thrombosis after hemorrhagic stroke than after acute ischemic stroke. JOURNAL OF VASCULAR NURSING 2019; 37:18-27. [DOI: 10.1016/j.jvn.2018.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 11/28/2022]
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11
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Current Practice Trends for Use of Early Venous Thromboembolism Prophylaxis After Intracerebral Hemorrhage. Neurosurgery 2017; 82:85-92. [DOI: 10.1093/neuros/nyx146] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 03/03/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Venous thromboembolism (VTE) is common after intracerebral hemorrhage (ICH). Guidelines recommend early VTE prophylaxis.
OBJECTIVE
To determine characteristics associated with early chemoprophylaxis (CP) after ICH in the Get With The Guidelines-Stroke registry.
METHODS
In this observational cohort study, we identified patients with ICH between January 1, 2009 and September 30, 2013, who (1) were non-ambulatory and/or not comfort care measures by hospital day 2; (2) were not transferred to another acute care facility; and (3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were as follows: (1) mechanical non-CP or (2) CP with or without mechanical prophylaxis. Early prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors independently associated with early CP use.
RESULTS
Among 74 283 patients with ICH from 1358 hospitals, 5929 (7.9%) received early CP, 66 444 (89.4%) received early mechanical/non-CP, and 1910 (2.6%) had no prophylaxis, mechanical or CP, within the first 2 days. There was no increase in early CP use over the study period; 60% of hospitals provided early CP to <9% of patients. In multivariable analysis, female sex, atrial fibrillation, diabetes, coronary, carotid, and peripheral artery disease, prior ischemic stroke or transient ischemic attack, hospital size >500 beds, and geographic region were independently associated with early vs no early CP use.
CONCLUSION
Nationwide, the large majority of ICH patients receive early mechanical VTE prophylaxis only, without CP. Patient comorbidities and hospital characteristics such as geographic location are determinants of higher use of early CP.
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Kim DY, Kim YH, Lee J, Chang WH, Kim MW, Pyun SB, Yoo WK, Ohn SH, Park KD, Oh BM, Lim SH, Jung KJ, Ryu BJ, Im S, Jee SJ, Seo HG, Rah UW, Park JH, Sohn MK, Chun MH, Shin HS, Lee SJ, Lee YS, Park SW, Park YG, Paik NJ, Lee SG, Lee JK, Koh SE, Kim DK, Park GY, Shin YI, Ko MH, Kim YW, Yoo SD, Kim EJ, Oh MK, Chang JH, Jung SH, Kim TW, Kim WS, Kim DH, Park TH, Lee KS, Hwang BY, Song YJ. Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016. BRAIN & NEUROREHABILITATION 2017. [DOI: 10.12786/bn.2017.10.e11] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Deog Young Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Min-Wook Kim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung-Bom Pyun
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Korea
| | - Woo-Kyoung Yoo
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Suk Hoon Ohn
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Kang Jae Jung
- Department of Physical Medicine and Rehabilitation, Eulji University Hospital & Eulji University School of Medicine, Korea
| | - Byung-Ju Ryu
- Department of Physical Medicine and Rehabilitation, Sahmyook Medical Center, Korea
| | - Sun Im
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung Ju Jee
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Ueon Woo Rah
- Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Korea
| | - Joo Hyun Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Min Ho Chun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Hee Suk Shin
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Seong Jae Lee
- Department of Rehabilitation Medicine, College of Medicine Dankook University, Korea
| | - Yang-Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University School of Medicine, Korea
| | - Si-Woon Park
- Department of Rehabilitation Medicine, Catholic Kwandong University International St Mary's Hospital, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Nam Jong Paik
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Sam-Gyu Lee
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School, Korea
| | - Ju Kang Lee
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Seong-Eun Koh
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Don-Kyu Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Korea
| | - Geun-Young Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Yong Il Shin
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Myoung-Hwan Ko
- Department of Physical Medicine and Rehabilitation, Chonbuk National University Medical School, Korea
| | - Yong Wook Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Seung Don Yoo
- Department of Physical Medicine and Rehabilitation, Kyung Hee University College of Medicine, Korea
| | - Eun Joo Kim
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Hospital, Korea
| | - Min-Kyun Oh
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Tae-Woo Kim
- TBI rehabilitation center, National Traffic Injury Rehabilitation Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Dae Hyun Kim
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Korea
| | - Kwan-Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Byong-Yong Hwang
- Department of Physical Therapy, Yong-In University College of Health & Welfare, Korea
| | - Young Jin Song
- Department of Rehabilitation Medicine, Asan Medical Center, Korea
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Prophylactic heparin in acute intracerebral hemorrhage: a propensity score-matched analysis of the INTERACT2 study. Int J Stroke 2016; 11:549-56. [DOI: 10.1177/1747493016641113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/17/2016] [Indexed: 11/15/2022]
Abstract
Background Indication and timing of pharmacological venous thromboembolism prophylaxis in intracerebral hemorrhage patients is controversial. Aims To determine whether use of subcutaneous heparin during the first 7 days after spontaneous intracerebral hemorrhage increases risks of death and disability. Methods Data are from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) study. Patients with acute intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure were included; patients received subcutaneous heparin following local best practice standards of care. Multivariable logistic regression and propensity score matched analysis were used to determine associations of heparin use on death and disability (modified Rankin scale) at 90 days. Results In 2525 patients with available data, there were 465 (22.5%) who received subcutaneous heparin. They had higher death or major disability at 90 days in crude (odds ratio 2.29, 95% confidence interval 1.85–2.84; p < 0.001), adjusted (odds ratio 1.62, 95% confidence interval 1.26–2.09; p < 0.001) and propensity score matched (odds ratio 2.06, 95% confidence interval 1.53–2.77; p < 0.001) analyses. In propensity score matched analysis, heparin-treated patients had significant lower mortality (odds ratio 0.55, 95% CI 0.35–0.87; p = 0.01) but greater major disability (odds ratio 1.68, 95% confidence interval 1.25–2.28; p < 0.001) at 90 days. However, no mortality difference was found in analysis restricted to 48-hour survivors. Conclusions Use of subcutaneous heparin is associated with poor outcome in acute intracerebral hemorrhage, driven by increased residual disability. Despite the limitations of this study, and no clear relation of heparin with bleeding risk, we recommend careful consideration of the need for venous thromboembolism prophylaxis with heparin in intracerebral hemorrhage patients. Trial registration http://www.clinicaltrials.gov NCT00716079.
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Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
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Prabhakaran S, Herbers P, Khoury J, Adeoye O, Khatri P, Ferioli S, Kleindorfer DO. Is Prophylactic Anticoagulation for Deep Venous Thrombosis Common Practice After Intracerebral Hemorrhage? Stroke 2015; 46:369-75. [DOI: 10.1161/strokeaha.114.008006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Prophylactic anticoagulation for deep venous thrombosis prevention after intracerebral hemorrhage (ICH) is safe. Current guidelines recommend prophylactic anticoagulation after cessation of hematoma growth. We aimed to evaluate nationwide trends in deep venous thrombosis prophylaxis after ICH.
Methods—
In an analysis of the Premier database, we identified adult patients with ICH (
International Classification of Diseases
Ninth edition code 431) from 2006 to 2010 who survived to day 2 of hospitalization. We excluded those with trauma or who underwent craniotomy or angiography. We abstracted type of anticoagulant used and date of first administration. We used univariate statistics and multivariable logistic regression to assess factors associated with prophylactic anticoagulation after ICH.
Results—
Among 32 690 (mean age, 69.7 years; 50.1% men) patients with spontaneous ICH, 5395 (16.5%) patients received any prophylactic anticoagulation during the hospital stay. Among these patients, 2416 (44.8%) received prophylactic anticoagulation by day 2. The most commonly used agents were heparin (71.1%), enoxaparin (27.5%), and dalteparin (1.4%). The proportion of patients receiving prophylactic anticoagulation increased slightly during the study period from 14.3% to 18.0% (
P
<0.01 for trend). Use of prophylactic anticoagulation varied by geographic region (
P
<0.001) in the United States: Northeast (23.2%), South (19.0%), Midwest (10.8%), and West (9.8%). In multivariable analysis, geographic region remained an independent predictor of prophylactic anticoagulation.
Conclusions—
Less than 20% of patients with ICH receive anticoagulation for deep venous thrombosis in the United States. When used, the time to initiation is <2 days in less than half of the patients. Further study should focus on understanding variations in practice and emphasize guideline-driven care.
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Affiliation(s)
- Shyam Prabhakaran
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Patricia Herbers
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Jane Khoury
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Opeolu Adeoye
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Pooja Khatri
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Simona Ferioli
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Dawn O. Kleindorfer
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
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Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJM, Krieger D, Mendelow AD, Molina C, Montaner J, Overgaard K, Petersson J, Roine RO, Schmutzhard E, Schwerdtfeger K, Stapf C, Tatlisumak T, Thomas BM, Toni D, Unterberg A, Wagner M. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9:840-55. [PMID: 25156220 DOI: 10.1111/ijs.12309] [Citation(s) in RCA: 495] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/23/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH. METHOD A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to <140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9-12, and avoidance of corticosteroids. CONCLUSION These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany; Department of Neurology, Heidelberg University, Heidelberg, Germany
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