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Diao H, Lu G, Wang Z, Zhang Y, Liu X, Ma Q, Yu H, Li Y. Risk factors and predictors of venous thromboembolism in patients with acute spontaneous intracerebral hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 244:108430. [PMID: 39032425 DOI: 10.1016/j.clineuro.2024.108430] [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: 05/23/2024] [Revised: 07/04/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and preventable complication of patients with acute spontaneous intracerebral hemorrhages (ICH). Knowledge of VTE risk factors in patients with acute spontaneous ICH continues to evolve while remains controversial. Therefore, this study aims to summarize the risk factors and predictors of VTE in patients with acute spontaneous ICH. METHODS EMBASE, PubMed, Web of Science and Cochrane databases were searched for articles containing Mesh words "Cerebral hemorrhage" and "Venous thromboembolism." Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. We performed meta-analysis to determine risk factors for the development of VTE in acute spontaneous ICH patients. Sensitivity analysis were performed to explore the sources of heterogeneity. RESULTS Of the 12,362 articles retrieved, 17 cohort studies were included.Meta-analysis showed that longer hospital stay [OR=15.46, 95 % CI (12.54, 18.39), P<0.00001], infection [OR=5.59, 95 % CI (1.53, 20.42), P=0.009], intubation [OR=4.32, 95 % CI (2.79, 6.69), P<0.00001] and presence of intraventricular hemorrhage (IVH) [OR=1.89, 95 % CI (1.50, 2.38), P<0.00001] were significant risk factors for VTE in acute spontaneous ICH patients. Of the 17 studies included, five studies reported six prediction models, including 15 predictors. The area under the receiver operating curve (AUC) ranged from 0.71 to 0.95. One of the models was externally validated. CONCLUSION Infection, the intubation, presence of IVH and longer hospital stay were risk factors for the development of VTE in acute spontaneous ICH patients. Prediction models of VTE based on acute spontaneous ICH patients have been poorly reported and more research will be needed before such models can be applied in clinical settings.
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Affiliation(s)
- Haiqing Diao
- School of Nursing, Yangzhou University, Yangzhou, Jiangsu, China
| | - Guangyu Lu
- School of Public Health, Yangzhou University, Yangzhou, Jiangsu, China
| | - Zhiyao Wang
- School of Clinical Medicine, Yangzhou University, Yangzhou, Jiangsu, China; Neuro-Intensive Care Unit, Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Yang Zhang
- School of Nursing, Yangzhou University, Yangzhou, Jiangsu, China
| | - Xiaoguang Liu
- Neuro-Intensive Care Unit, Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Qiang Ma
- Neuro-Intensive Care Unit, Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Hailong Yu
- Neuro-Intensive Care Unit, Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Yuping Li
- Neuro-Intensive Care Unit, Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China; Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu, China.
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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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Grainger BT, McFadyen JD, Tran H. Between a rock and a hard place: resumption of oral anticoagulant therapy after intracranial hemorrhage. J Thromb Haemost 2024; 22:594-603. [PMID: 37913910 DOI: 10.1016/j.jtha.2023.10.020] [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: 06/06/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
Intracranial hemorrhage (ICH) is the most feared and lethal complication of oral anticoagulant (OAC) therapy. Resumption of OAC after ICH has long posed a challenge for clinicians, complicated by the expanding range of anticoagulant agents available in modern clinical practice, including direct OACs and, more recently, factor XI and XII inhibitors. A review of the current literature found support for resuming OAC in the majority of patients after ICH based on pooled retrospective data showing that resumption is associated with a lower risk of mortality and thromboembolism without a significantly increased risk of recurrent hemorrhage. The optimal time to resume OAC is less clear; however, the available evidence suggests that the composite risk of both recurrent hemorrhage and thromboembolism is likely minimized, somewhere between 4 and 6 weeks, after ICH in most patients. Specific considerations to guide the optimal resumption time in the individual patient include ICH location, mechanism, and anticoagulant class. Patients with mechanical heart valves and intracerebral malignancy represent high-risk groups who require more nuanced decision making. Here, we appraise the literature with the aim of providing a practical guide for clinicians while also discussing priorities for future investigation.
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Affiliation(s)
- Brian T Grainger
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Huyen Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Zhang R, Sun W, Xing Y, Wang Y, Li Z, Liu L, Gu H, Yang K, Yang X, Wang C, Liu Q, Xiao Q, Cai W. Implementation of early prophylaxis for deep-vein thrombosis in intracerebral hemorrhage patients: an observational study from the Chinese Stroke Center Alliance. Thromb J 2024; 22:22. [PMID: 38419108 PMCID: PMC10900581 DOI: 10.1186/s12959-024-00592-w] [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: 12/11/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND There is substantial evidence to support the use of several methods for preventing deep-vein thrombosis (DVT) following intracerebral hemorrhage (ICH). However, the extent to which these measures are implemented in clinical practice and the factors influencing patients' receipt of preventive measures remain unclear. Therefore, we aimed to evaluate the rate of the early implementation of DVT prophylaxis and the factors associated with its success in patients with ICH. METHODS This study enrolled 49,950 patients with spontaneous ICH from the Chinese Stroke Center Alliance (CSCA) between August 2015 and July 2019. Early DVT prophylaxis implementation was defined as an intervention occurring within 48 h after admission. Univariate and multivariate logistic regression analyses were conducted to identify the rate and factors associated with the implementation of early prophylaxis for DVT in patients with ICH. RESULTS Among the 49,950 ICH patients, the rate of early DVT prophylaxis implementation was 49.9%, the rate of early mobilization implementation was 29.49%, and that of pharmacological prophylaxis was 2.02%. Factors associated with an increased likelihood of early DVT prophylaxis being administered in the multivariable model included receiving early rehabilitation therapy (odds ratio [OR], 2.531); admission to stroke unit (OR 2.231); admission to intensive care unit (OR 1.975); being located in central (OR 1.879) or eastern regions (OR 1.529); having a history of chronic obstructive pulmonary disease (OR 1.292), ischemic stroke (OR 1.245), coronary heart disease or myocardial infarction (OR 1.2); taking antihypertensive drugs (OR 1.136); and having a higher Glasgow Coma Scale (GCS) score (OR 1.045). Conversely, being male (OR 0.936), being hospitalized in tertiary hospitals (OR 0.778), and having a previous intracranial hemorrhage (OR 0.733) were associated with a lower likelihood of early DVT prophylaxis being administered in patients with ICH. CONCLUSIONS The implementation rate of early DVT prophylaxis among Chinese patients with ICH was subpar, with pharmacological prophylaxis showing the lowest prevalence. Various controllable factors exerted an impact on the implementation of early DVT prophylaxis in this population.
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Affiliation(s)
- Ran Zhang
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, 100070, Beijing, China
| | - Weige Sun
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, 100070, Beijing, China
| | - Yana Xing
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, 100070, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Kaixuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Xin Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Qingbo Liu
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, 100070, Beijing, China
| | - Qian Xiao
- School of Nursing, Capital Medical University, 100069, Beijing, China.
| | - Weixin Cai
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, 100070, Beijing, China.
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Imbalzano E, Orlando L, Dattilo G, Gigliotti De Fazio M, Camporese G, Russo V, Perrella A, Bernardi FF, Di Micco P. Update on the Pharmacological Actions of Enoxaparin in Nonsurgical Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:156. [PMID: 38256416 PMCID: PMC11154512 DOI: 10.3390/medicina60010156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Low-molecular-weight heparins are a class of drugs derived from the enzymatic depolymerization of unfractionated heparin that includes enoxaparin. Several studies have been performed on enoxaparin in recent years, in particular for the prevention and treatment of venous thromboembolism and for the treatment of acute coronary syndrome. Furthermore, the use of enoxaparin has been extended to other clinical situations that require antithrombotic pharmacological prevention, such as hemodialysis and recurrent abortion. In this review, we report the main clinical experiences of using enoxaparin in the prevention of VTE in nonsurgical patients.
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Affiliation(s)
- Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.I.); (L.O.); (G.D.); (M.G.D.F.)
| | - Luana Orlando
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.I.); (L.O.); (G.D.); (M.G.D.F.)
| | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.I.); (L.O.); (G.D.); (M.G.D.F.)
| | - Marianna Gigliotti De Fazio
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.I.); (L.O.); (G.D.); (M.G.D.F.)
| | - Giuseppe Camporese
- General Medicine Department, Thrombotic and Haemorrhagic Disorders Unit, Department of Internal Medicine, University Hospital of Padua, 35131 Padua, Italy;
| | - Vincenzo Russo
- Department of Translational Science, University Vanvitelly, 81025 Caserta, Italy;
| | - Alessandro Perrella
- Unit Emerging Infectious Disease, Ospedali dei Colli, P.O. D. Cotugno, 80131 Naples, Italy;
| | - Francesca Futura Bernardi
- Department of Experimental Medicine, Università degli Studi della Campania Luigi Vanvitelli, 80100 Naples, Italy;
| | - Pierpaolo Di Micco
- AFO Medicina, P.O. Santa Maria delle Grazie, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
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Ansari Z, Rafiq Y, Arif H, Shahid F. Comment on "Venous thromboembolism after spontaneous intracerebral hemorrhage and the status quo of anticoagulation in this population: A retrospective case-control study from a tertiary hospital in China". Clin Neurol Neurosurg 2023; 233:107954. [PMID: 37689013 DOI: 10.1016/j.clineuro.2023.107954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Zobia Ansari
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Youmna Rafiq
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan.
| | - Hafsa Arif
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan.
| | - Fatima Shahid
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan.
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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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Sinha S, Ahuja B, Pandit R, Mishra R, Chatterjee R, Choudhuri AH. Thromboprophylaxis practices in neurocritical care-A cross-sectional survey among neurocritical care practitioners. Indian J Anaesth 2023; 67:703-707. [PMID: 37693020 PMCID: PMC10488571 DOI: 10.4103/ija.ija_862_22] [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: 10/19/2022] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Aims Thromboprophylaxis practice patterns are quite diverse in neurocritical care patients. The risk of venous thromboembolism remains high in this group due to prolonged immobilised status, extended length of stay and multiple comorbidities. The aim was to comprehend the thromboprophylaxis practices among neurocritical care practitioners in India. Methods The cross-sectional online questionnaire-based survey was undertaken among the neurocritical care practitioners. Two investigators framed two sets of 15 questions in the first stage and reviewed them with experts. In the second stage, a set of 22 questions was prepared by a third investigator and pretested among ten experts. The questions were emailed to the participants with a link to the survey. The responses were analysed using Statistical Package For The Social Sciences software. Results Of the 185 responses, 53% reported that thromboprophylaxis is practised less often in neurocritical care than in general critical care. The usage of pharmacoprophylaxis among neurosurgical cases, traumatic brain injuries and brain strokes varies widely. There was a preference to use pharmacoprophylaxis in patients with Glasgow Coma Scale (GCS) below nine among many (68.2%), and low molecular weight heparin (LMWH) was the preferred choice in such cases. The reluctance to use heparin because of fear of bleed was high (82%). Most (78.9%) believed pharmacoprophylaxis could reduce venous thromboembolic events (VTEs) and mortality. Conclusion Thromboprophylaxis practices among neurocritical care patients remain quite heterogeneous. There is a dilemma in patients with intracranial haemorrhagic lesions regarding pharmacoprophylaxis.
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Affiliation(s)
- Sharmili Sinha
- Senior Consultant, Critical Care, Apollo Hospital, Bhubaneswar, Odisha, India
| | | | - Rahul Pandit
- Critical Care, Sir HN Reliance Foundation Hospital, Mumbai, Maharashtra, India
| | - Rajesh Mishra
- Intensivist and Internist, Ahmedabad, Gujarat, India
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9
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Mazzoleni V, Padovani A, Morotti A. Emergency management of intracerebral hemorrhage. J Crit Care 2023; 74:154232. [PMID: 36565647 DOI: 10.1016/j.jcrc.2022.154232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Acute intracerebral hemorrhage is a medical emergency with high mortality and morbidity. Neuroimaging has a fundamental role in the etiological diagnosis, patients monitoring and in the risk stratification of hematoma expansion and poor outcome. The cornerstones of medical treatment in the acute phase are blood pressure lowering and coagulopathy reversal. Prevention of hematoma expansion is the main goal of these therapies and their efficacy is strongly time-dependent with a narrow time window. This review provides an update on the etiological diagnostic workup, acute treatment and prognosis of intracerebral hemorrhage.
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Affiliation(s)
- Valentina Mazzoleni
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy; Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
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10
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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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11
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Chen L, Zhang W, Liu C. Combination of D-dimer and Albumin in the Prediction of Deep Vein Thrombosis in Patients with Spontaneous Intracerebral Hemorrhage. Clin Appl Thromb Hemost 2023; 29:10760296231165054. [PMID: 36946100 PMCID: PMC10034306 DOI: 10.1177/10760296231165054] [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: 03/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Deep venous thrombosis (DVT) makes spontaneous intracerebral hemorrhage (ICH) treatment more challenging. We aimed to determine the predictive ability of D-dimer combination with albumin for DVT in spontaneous ICH. METHODS Spontaneous ICH patients were retrospectively included. Univariate and multivariate logistic regression analyses were performed. The restricted cubic spline (RCS) curve was adopted. Multivariate logistic regression analysis was further conducted to assess the predictive powers of D-dimer and albumin in different models. Besides, the incremental predictive ability of D-dimer combination with albumin was evaluated with areas under the curve (AUC), net reclassification improvement (NRI), and integrated discrimination index (IDI). RESULTS D-dimer was significantly higher, while albumin was considerably lower in the DVT group than in the non-DVT group [D-dimer, 0.47 (0.29, 1.08) versus 0.98 (0.48, 2.49), P < .001; albumin, 39.45 ± 7.05 versus 36.93 ± 4.77, P < .001). The multivariate logistic regression analysis showed that higher D-dimer and lower albumin were independently related to DVT after controlling confounders (D-dimer, OR = 1.061, 95% CI = 1.012-1.112, P = .013; albumin, OR = 0.934, 95% CI = 0.895-0.973, P = .001). The best cut-off value of the D-dimer was 0.40, and the albumin was 37.15. Besides, D-dimer and albumin had good predictive abilities in different models. The AUC, NRI, and IDI revealed that models that included the D-dimer combination with albumin had better predictability than those without. CONCLUSIONS D-dimer combination with albumin has a good predictability of DVT in spontaneous ICH.
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Affiliation(s)
- Lingli Chen
- Department of Neurology, 625444The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wanli Zhang
- Department of Neurology, 89657The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chunfeng Liu
- Department of Neurology, 625444The Second Affiliated Hospital of Soochow University, Suzhou, China
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Zou J, Chen H, Liu C, Cai Z, Yang J, Zhang Y, Li S, Lin H, Tan M. Development and validation of a nomogram to predict the 30-day mortality risk of patients with intracerebral hemorrhage. Front Neurosci 2022; 16:942100. [PMID: 36033629 PMCID: PMC9400715 DOI: 10.3389/fnins.2022.942100] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/15/2022] [Indexed: 12/28/2022] Open
Abstract
Background Intracerebral hemorrhage (ICH) is a stroke syndrome with an unfavorable prognosis. Currently, there is no comprehensive clinical indicator for mortality prediction of ICH patients. The purpose of our study was to construct and evaluate a nomogram for predicting the 30-day mortality risk of ICH patients. Methods ICH patients were extracted from the MIMIC-III database according to the ICD-9 code and randomly divided into training and verification cohorts. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression were applied to determine independent risk factors. These risk factors were used to construct a nomogram model for predicting the 30-day mortality risk of ICH patients. The nomogram was verified by the area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA). Results A total of 890 ICH patients were included in the study. Logistic regression analysis revealed that age (OR = 1.05, P < 0.001), Glasgow Coma Scale score (OR = 0.91, P < 0.001), creatinine (OR = 1.30, P < 0.001), white blood cell count (OR = 1.10, P < 0.001), temperature (OR = 1.73, P < 0.001), glucose (OR = 1.01, P < 0.001), urine output (OR = 1.00, P = 0.020), and bleeding volume (OR = 1.02, P < 0.001) were independent risk factors for 30-day mortality of ICH patients. The calibration curve indicated that the nomogram was well calibrated. When predicting the 30-day mortality risk, the nomogram exhibited good discrimination in the training and validation cohorts (C-index: 0.782 and 0.778, respectively). The AUCs were 0.778, 0.733, and 0.728 for the nomogram, Simplified Acute Physiology Score II (SAPSII), and Oxford Acute Severity of Illness Score (OASIS), respectively, in the validation cohort. The IDI and NRI calculations and DCA analysis revealed that the nomogram model had a greater net benefit than the SAPSII and OASIS scoring systems. Conclusion This study identified independent risk factors for 30-day mortality of ICH patients and constructed a predictive nomogram model, which may help to improve the prognosis of ICH patients.
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Affiliation(s)
- Jianyu Zou
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Huihuang Chen
- Department of Rehabilitation, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Cuiqing Liu
- Department of Nursing, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhenbin Cai
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jie Yang
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yunlong Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shaojin Li
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hongsheng Lin
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Hongsheng Lin,
| | - Minghui Tan
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Minghui Tan,
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Li L, Murthy SB. Cardiovascular Events After Intracerebral Hemorrhage. Stroke 2022; 53:2131-2141. [DOI: 10.1161/strokeaha.122.036884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.
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Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L.)
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (S.B.M.)
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