The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves

Recommencing anticoagulation treatment in surgically managed patients with intracerebral haemorrhage and mechanical heart valves: An Aotearoa-New Zealand analysis

PURPOSE

Intracerebral haemorrhage (ICH) is an absolute contraindication for therapeutic oral anticoagulation therapy (OAT). Re-bleeding carries significant risk of morbidity and mortality. Patients with prosthetic heart valves are at higher risk of thromboembolic complications when OAT is withheld. The aim of our study is to establish the safe time periods where OAT can recommence, and assess the complication rates of re-introduction and associated risk factors.

METHODOLOGY

New Zealand-wide, retrospective (2005-2021) and prospective (2021-2023) data was collected from patients with prosthetic heart valves, aged 18 years or older who underwent surgical management of ICH. The time to re-bleeding or thromboembolic event was recorded and the time period that balances the risks was examined. Primary outcomes included rate of re-bleeding and thromboembolic events. Associated medical, radiological, surgical and valve risk factors were examined.

RESULTS

Thirty patients were identified and included in the analysis. Average time to therapeutic anticoagulation was 12.2 days post-op (95 % CI 6.9 - 17.5 days), 62.5 % recommenced OAT at or before day 14 (Range 3-13 days). Four patients (13.3 %) sustained a re-bleeding event after recommencing OAT. Three of the 4 re-bleeding events were observed in the group recommencing prior day 14, without reaching statistical significance. Of these, two patients died following the event. Group mortality was 30 %. One patient had a thromboembolic complication at day 14 post OAT, age of valve was 2 months. No thromboembolic complications were observed in patients recommencing after day 14. Maori and Pasifika patients were disproportionately represented and their condition was associated with a background of Rheumatic Heart Disease in 10 out of 11 cases.

CONCLUSION

Early re-commencing of OAT is effective in preventing thromboembolic complications associated to prosthetic heart valves. There is a tendency for re-bleeding to occur when OAT is recommenced prior to day 14 (not significant). These data suggest that in this New Zealand cohort, the thromboembolic risks of withholding OAT may be overestimated at the expense of early anticoagulation, with an increased risk of re-bleeding in this surgically managed cohort. Further prospective studies are warranted to definitively examine the risks of early therapeutic anticoagulation in this group.

Anticoagulation for Mechanical Aortic Valve in a Patient With Aortic Dissection and Pulmonary Hemorrhage: A Case Report

Acute aortic dissections are considered surgical emergencies because they are catastrophic bleeding events. The risk of bleeding is further increased if the patient requires anticoagulation for other comorbidities, such as a mechanical heart valve.  This case study describes a 73-year-old gentleman who presented with massive hemoptysis due to an acute aortic dissection complicated by pulmonary hemorrhage in the context of previous aortic dissection with multiple repair surgeries and residual chronic aortic dissection. He was also on warfarin for a mechanical aortic valve complicated by supratherapeutic international normalized ratio. His acute aortic dissection was treated conservatively without surgery, and he survived. Concerning the risk of thromboembolism from the mechanical aortic valve, anticoagulation was reintroduced one week after his initial bleeding. We changed warfarin to enoxaparin, which was started at a small dose, 40 mg subcutaneously once a day, then gradually increased to the full therapeutic dose, 90 mg (1 mg/kg) twice daily over a week. He was not fully anticoagulated for two weeks. Fortunately, he did not develop any thrombosis. Hemoglobin and Factor Xa levels were closely monitored. He tolerated the enoxaparin without further bleeding.  This type of case is rare and has not been previously reported, considering the patient survived acute aortic dissection with conservative management, did not develop any thrombosis from the mechanical aortic valve when anticoagulation was withheld, and did not experience rebleeding when anticoagulation was restarted. Further research and guidelines are needed to assist clinicians in managing anticoagulation when facing the dilemmas of the risk of bleeding and the risk of thromboembolism. This is particularly important in complex scenarios, such as for patients with mechanical heart valves who subsequently develop contraindications such as aortic dissection or other life-threatening bleeding events.

Timing of Anticoagulation Resumption and Risk of Ischemic and Hemorrhagic Complications in Patients With ICH and Mechanical Heart Valves

BACKGROUND AND OBJECTIVES

In patients with mechanical heart valves and recent intracranial hemorrhage (ICH), clinicians need to balance the risk of thromboembolism during the period off anticoagulation and the risk of hematoma expansion on anticoagulation. The optimal timing of anticoagulation resumption is unknown. We aimed to investigate the relationship between reversal therapy and ischemic stroke, between duration off anticoagulation and risk of ischemic strokes or systemic embolism and between timing of anticoagulation resumption and risk of rebleeding and ICH expansion.

METHODS

We conducted a retrospective cohort observational study in 3 tertiary hospitals. Consecutive adult patients with mechanical heart valves admitted for ICH between January 1, 2000, and July 13, 2022, were included. The primary end points of our study were thromboembolic events (cerebral, retinal, or systemic) while off anticoagulation and ICH expansion after anticoagulation resumption (defined by the following criteria: increase by one-third in intracerebral hematoma volume, increase by one-third in convexity subdural hemorrhage diameter, or visually unequivocal expansion of other ICH locations to the naked eye).

RESULTS

A total of 171 patients with mechanical heart valves who experienced ICH were included in the final analysis. Most of the patients (79.5%) received reversal therapy for anticoagulation. Patients who received anticoagulation reversal therapy did not have increased risk of thromboembolic complications. Time off anticoagulation was not associated with risk of ischemic stroke; only 2 patients had a stroke within 7 days of the ICH, and both had additional major risk factors of thromboembolism. The rate of ischemic stroke/transient ischemic attack while off anticoagulation was lower than the rate of ICH expansion once anticoagulation was resumed (6.4% vs 9.9%). Furthermore, patients who developed ICH expansion had higher mortality compared with patients who had ischemic stroke while being off anticoagulation (41% vs 9%). Use of intravenous heparin bridging upon resumption of warfarin was strongly associated with increased risk of ICH expansion as compared with restarting warfarin without a heparin bridge.

DISCUSSION

Withholding anticoagulation for at least 7 days after ICH may be safe in patients with mechanical heart valves. Heparin bridging during anticoagulation resumption may be associated with increased risk of bleeding.

Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves

BACKGROUND

Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain.

METHODS AND RESULTS

We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098).

CONCLUSIONS

In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Resuming Anticoagulants in Patients With Intracranial Hemorrhage: A Meta-Analysis and Literature Review

BACKGROUND AND OBJECTIVES

Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH.

METHODS

Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis.

RESULTS

Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0).

CONCLUSION

Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH.

Thrombotic and Hemorrhagic Complications Following Left Ventricular Assist Device Placement: An Emphasis on Gastrointestinal Bleeding, Stroke, and Pump Thrombosis

The left ventricular assist device (LVAD) is a mechanical circulatory support device that supports the heart failure patient as a bridge to transplant (BTT) or as a destination therapy for those who have other medical comorbidities or complications that disqualify them from meeting transplant criteria. In patients with severe heart failure, LVAD use has extended survival and improved signs and symptoms of cardiac congestion and low cardiac output, such as dyspnea, fatigue, and exercise intolerance. However, these devices are associated with specific hematologic and thrombotic complications. In this manuscript, we review the common hematologic complications of LVADs.

Cerebral infarction following administration of andexanet alfa for anticoagulant reversal in a patient with traumatic acute subdural hematoma

Background

Anticoagulants prevent thrombosis in patients with atrial fibrillation (AF) and venous thromboembolism but increase the risk of hemorrhagic complications. If severe bleeding occurs with anticoagulant use, discontinuation and rapid reversal are essential. However, the optimal timing for resuming anticoagulants after using reversal agents remains unclear. Here, we report early cerebral infarction following the use of andexanet alfa (AA), a specific reversal agent for factor Xa inhibitors, in a patient with traumatic acute subdural hematoma (ASDH). The possible causes of thromboembolic complication and the optimal timing for anticoagulant resumption are discussed.

Case Description

An 84-year-old woman receiving rivaroxaban for AF presented with impaired consciousness after a head injury. Computed tomography (CT) revealed right ASDH. The patient was administered AA and underwent craniotomy. Although the hematoma was entirely removed, she developed multiple cerebral infarctions 10 h after the surgery. These infarctions were considered cardiogenic cerebral embolisms and rivaroxaban was therefore resumed on the same day. This case indicates the possibility of early cerebral infarction after using a specific reversal agent for factor Xa inhibitors.

Conclusion

Most studies suggest that the safest time for resuming anticoagulants after using reversal agents is between 7 and 12 days. The present case showed that embolic complications may develop much earlier than expected. Early readministration of anticoagulant may allow for adequate prevention of the acute thrombotic syndromes.

Acute Traumatic Subdural Hematoma and Anticoagulation Risk

BACKGROUND

Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI.

METHODS

Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected.

RESULTS

41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large.

CONCLUSION

Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

Spontaneous bilateral subdural hematoma in a patient with a prosthetic valve and association with plasmodium vivax malaria: A rare case report

Introduction and importance

Bilateral subdural hematoma (SDH) is a very rare condition which can occur without any apparent etiology. It's characterized by a lower frequency of focal neurological impairments, which could delay the diagnosis and postpone treatment. The reported incidence of an acute spontaneous subdural hematoma (SSH) varies between 2% and 6.7% of all acute SDH. SDH following Plasmodium vivax (P. vivax) infection are uncommon to our knowledge, only two cases of SDH linked with P. vivax infection have been documented in the literature.

Case presentation

We describe a case of a 31-year-old male with a history of mitral mechanical valve replacement on anti-coagulant presented with spontaneous bilateral subdural hematoma in the presence of malaria. The patient had a limited vague symptom, which delayed a prompt diagnosis of his disease.

Clinical discussion

Spontaneous subdural hematoma has only a few documented cases. Hypertension, infections, vascular malformations, ruptured aneurysms, thrombocytopenia caused by hematological and oncological illnesses, acquired or inherited types of coagulopathies, and drug abuse are all risk factors. Also, SDH has been documented in the literature as a consequence of Plasmodium infection. In addition to that this patient was on anti-epileptic medicines which might potentiate vitamin K antagonists. Numerous factors were thought to have contributed to this significant bleeding.

Conclusion

Patients on anticoagulants who exhibit nebulous symptoms, including a mild headache, should be subjected to a thorough history and examination. And any factor delaying an accurate diagnosis should be eliminated. This will complement the patient's plan and management.

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Patients taking anticoagulants who experience a slight headache should be considered a risk symptom in endemic areas where malaria is frequent.

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In anticoagulation patients, malaria can be aggravating factor for high bleeding, in Such patients should be subjected to a complete history and examination.

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Any misinterpreting factors impacting medication pharmacodynamics and pharmacokinetics should be investigated for patients taking anticoagulants. This will be a role in the patient's approach and will pave the way for the other management strategy.

Ultra-early therapeutic anticoagulation after craniotomy - A single institution experience

There is a paucity of information regarding the optimal timing of initiation or re-initiation of therapeutic anticoagulation after intracranial surgery. Anticoagulation that is started too soon after surgery may increase the risk of catastrophic intracranial bleeding. However, there are scenarios that necessitate the use of anticoagulation in the immediate post-operative period despite the increased risk of hemorrhage. Therefore, we sought to report our experience with ultra-early therapeutic anticoagulation after craniotomy. Retrospective chart review of patients from a single institution between 1/1/2010 and 10/1/2021 who were treated with therapeutic anticoagulation for venous thromboembolism on or before 7-days after a craniotomy or craniectomy. The primary endpoint was intracranial hemorrhage resulting in death or return to the operating room for hematoma evacuation. Secondary endpoints included extra-cranial hemorrhage, length of hospital stay, and 90-day readmission rate. Eighteen patients were included for analysis. The median time that therapeutic anticoagulation was started was post-operative day 5 (range 1-7 days). One patient (5.6%) met the primary endpoint as they experienced an intracranial hemorrhage 5 days after starting anticoagulation, which required surgical evacuation. No patients experienced an extra-cranial hemorrhage. The median length of hospitalization was 13 days (range 4-89 days). No patients were readmitted within 90 days. The 90-day survival rate was 100%. Ultra-early anticoagulation after craniotomy resulted in a 5.6% risk of intracranial hemorrhage. Thus, ultra-early anticoagulation can be performed safely but it does carry a substantial risk of intracranial bleeding that may require emergent hematoma evacuation or result in permeant neurologic deficits or death.

Resumption of anticoagulation therapy after spontaneous intracerebral hemorrhage with patients mechanical heart valves

Background

Patients with mechanical heart valves are usually maintained on anticoagulation therapy. However, after a spontaneous intracerebral hemorrhage event, administration of anticoagulants is temporarily ceased, and it remains unclear when to restart anticoagulation therapy.

Methods

A cohort study was conducted to investigate the optimal time for restarting anticoagulation in patients with mechanical heart valves after spontaneous intracerebral hemorrhage. All patients with mechanical valves who experienced spontaneous cerebral hemorrhage and were admitted to the Second Affiliated Hospital of the Zhejiang University Medical School between 2013 and 2018 were retrospectively enrolled in this study. The patient electronic medical records were reviewed and the correlation between the time of restarting anticoagulation (within 3 days or more than 3 days after hemorrhage) and patient prognosis was assessed.

Results

A total of 40 patients with mechanical heart valves who experienced spontaneous cerebral hemorrhage were enrolled in this study. All patients were given oral warfarin anticoagulant therapy prior to admission (1.5–3.25 mg). After admission, patients were administered fresh frozen plasma and/or vitamin K1 to reverse anticoagulation. Out of the 16 patients (40%) who underwent surgical intervention, 4 died from cerebral hemorrhage deterioration during the hospital stay and did not restart anticoagulant therapy. Anticoagulant therapy was resumed within 3 days for 18 patients and more than three days after hemorrhage for the other 18 patients. After discharge, patients were followed up for 12 months or more. Unfortunately, during this period, 17% of patients (6/36) died.

Conclusions

Definitive hemostatic measures can be as an important factor in the clinical resumption of anticoagulation. Halting anticoagulant therapy for 3 to 7 days may be safe. It is recommended that low molecular heparin be administered within 3 days as a bridge treatment, combine with warfarin anticoagulant therapy within 1 week after hemorrhage.

Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves

Valvular heart disease is common in the United States, with a number of patients undergoing valve replacement procedures every year. The two types of valve prostheses include mechanical and bioprosthetic valves. Mechanical heart valves require lifelong anticoagulation with vitamin K antagonists like warfarin. The clinicians are often faced with the dilemma of major bleeding episodes such as intracranial hemorrhage or gastrointestinal bleeding in these patients. The management includes reversing warfarin-induced coagulopathy with vitamin K supplementation, fresh frozen plasma, or prothrombin complex concentrate (PCC), with PCC being the treatment of choice. With regard to the safe resumption of anticoagulation, guidelines are silent, and data is limited to case reports/series. This article reviews the present literature for the management of bleeding in patients with mechanical heart valves and the safe duration for holding off anticoagulation with minimal risk of valve thrombosis/thromboembolism.

Timing of Restarting Anticoagulation and Antiplatelet Therapies After Traumatic Subdural Hematoma-A Single Institution Experience

BACKGROUND

There is a paucity of information regarding the optimal timing of restarting antiplatelet therapy (APT) and anticoagulation therapy (ACT) after traumatic subdural hematoma (tSDH). Therefore, we sought to report our experience at a single level 1 trauma center with regard to restarting APT and/or ACT after tSDH.

METHODS

A total of 456 consecutive records were reviewed for unplanned hematoma evacuation within 90 days of discharge and thrombotic/thromboembolic events before restarting APT and/or ACT.

RESULTS

There was no difference in unplanned hematoma evacuation rate in patients not receiving APT or ACT (control) compared with those necessitating APT and/or ACT (6.4% control, 6.9% APT alone, 5.8% ACT alone, 5.4% APT and ACT). There was an increase in post-tSDH thrombosis/thromboembolism in patients needing to restart ACT (1.9% APT alone, P = 0.53 vs. control; 5.8% ACT alone, P = 0.04 vs. control; 16% APT and ACT; P < 0.001 vs. control). Subgroup analysis revealed that patients with coronary artery disease necessitating APT and patients with atrial fibrillation necessitating ACT had higher thrombosis/thromboembolism rates compared with controls (1.0% control vs. 6.1% coronary artery disease, P = 0.02; 1.0% control vs. 10.1% atrial fibrillation, P < 0.001). The median restart time of ACT was approximately 1 month after trauma; APT was restarted 2-4 weeks after trauma depending on clinical indication.

CONCLUSIONS

Patients requiring reinitiation of APT and/or ACT after tSDH were at elevated risk of thrombotic/thromboembolic events but not unplanned hematoma evacuation. Therefore, patients should be followed closely until APT and/or ACT are restarted, and consideration for earlier reinitiation of blood thinners should be given on a case-by-case basis.

Surgical treatment for antiplatelet intracerebral hemorrhage (SAP-ICH): protocol for a prospective cohort study of emergency surgery for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment

Background

Despite the capability of emergency surgery to reduce the mortality of severe spontaneous intracranial hemorrhage (SSICH) patients, the effect and safety of surgical treatment for severe spontaneous intracranial hemorrhage (SSICH) patients receiving long-term oral antiplatelet treatment (LOAPT) remains unclear. In consideration of this, the cohort study is aimed at figuring out the effect and safety of emergency surgery for SSICH patients on LOAPT.

Methods

As a multicenter and prospective cohort study, it will be conducted across 7 representative clinical centers. Starting in September 2019, the observation is scheduled to be completed by December 2022, with a total of 450 SSICH patients recruited. The information on clinical, radiological, and laboratory practices will be recorded objectively. All of the patients will be monitored until death or 6 months after the occurrence of primary hemorrhage.

Results

In this study, two comparative cohorts and an observational cohort will be set up. The primary outcome is the effect of emergency surgery, which is subject to assessment using the total mortality and comparison in the survival rate of SSICH patients on LOAPT between surgical treatment and conservative treatment. The second outcome is the safety of surgery, with the postoperative hemorrhagic complication which is compared between the operated SSICH patients on and not on LOAPT. Based on the observation of the characteristics and outcome of SSICH patients on LOAPT, the ischemic events after discontinuing LOAPT will be further addressed, and the coagulation function assessment system for operated SSICH patients on LOAPT will be established.

Conclusions

In this study, we will investigate the effect and safety of emergency surgery for SSICH patients on LOAPT, which will provide an evidence for management in the future.

Ethics and dissemination

The research protocol and informed consent in this study were approved by the Institutional Review Board of Beijing Tiantan Hospital (KY2019-096-02). The results of this study are expected to be disseminated in peer-reviewed journals in 2023.

Trial registration

Name: Effect and safety of surgical intervention for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment.

ChiCTR1900024406. Date of registration is July 10, 2019.

Warfarin-associated intracranial haemorrhage in pregnant woman with double mechanical valve replacement: a case presentation

BACKGROUND

Management of warfarin-associated major haemorrhage in prosthetic valve diseases is difficult as there is a fine line between haemorrhage and thrombosis. An individual's propensity towards thrombosis, such as pregnancy, makes this situation even more complicated. Cases like these are very rare in the literature.

CASE PRESENTATION

A 26 weeks pregnant, gravida two, para one, 35-year-old patient with prosthetic aortic and mitral valves presented to an external emergency clinic with clouding of consciousness. Her international normalised ratio(INR) was 8.9 at presentation. Brain MRI revealed a left subdural haematoma with no significant mass effect. Warfarin treatment was discontinued. On the second day of follow-up, she was referred to our centre for further evaluation of her clinical deterioration. She was haemodynamically stable on admission to the intensive care unit and followed up with a stable condition until the fourth day when she developed right eye drop and subsequent loss of consciousness. Her haematoma was surgically evacuated, and her condition improved. Eventually, she and a healthy newborn were discharged.

CONCLUSION

Intracranial haemorrhage during pregnancy is a relatively rare complication that requires a multidisciplinary management plan. Although the thrombogenic risk is high, it is vital to complete a reversal of warfarin anticoagulation in pregnant women with major bleeding.

Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review

BACKGROUND

Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease.

OBJECTIVE

The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy.

METHODS AND MATERIALS

We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy.

CONCLUSION

Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.

Restarting Therapeutic Anticoagulation After Elective Craniotomy for Patients with Chronic Atrial Fibrillation: A Review of the Literature

The decision to restart systemic anticoagulation after surgery requires a nuanced risk-benefit analysis. The potential for surgical site bleeding must be balanced against the risk of thromboembolic events. In the context of postoperative neurosurgical patients, the consequences of either hemorrhage or thromboembolism can be devastating. However, few studies to date have attempted to determine the optimal time to resume anticoagulation after craniotomy. As a result, the decision of when to restart anticoagulation remains largely subjective and highly variable between surgeons and institutions. In this study, we aim to develop an algorithm that incorporates existing metrics and expert opinion toward the goal of developing guidelines for restarting anticoagulation after elective craniotomy.

Reversal and Resumption of Antithrombotic Therapy in LVAD-Associated Intracranial Hemorrhage

BACKGROUND

Little data exist regarding reversal and resumption of antithrombotics after left ventricular assist device (LVAD)-associated intracranial hemorrhage.

METHODS

Prospectively collected data of LVAD patients with intracranial hemorrhage were reviewed. Coagulopathy reversal agents, antithrombotic regimens, and thrombotic (venous thromboembolism, ischemic stroke, myocardial infarction) and hemorrhagic (recurrent intracranial hemorrhage, gastrointestinal bleed, anemia requiring transfusion) complications were recorded.

RESULTS

Of 405 patients, intracranial hemorrhage occurred in 39 (10%): 23 intracerebral hemorrhages, 10 subarachnoid hemorrhages, and 6 subdural hematomas. Of 27 patients who received antithrombotic reversal, 8 (30%) had inadequate coagulopathy reversal, and 3 of these patients had hemorrhage expansion or died before repeat imaging. One (4%) patient had a thrombotic complication (deep vein thrombosis). Antithrombotic therapy was resumed in 17 (100%) survivors in a median time 8 days for antiplatelet agents and 14 days for warfarin. Recurrent intracranial hemorrhage occurred within a median of 7 days of antithrombotic resumption, while ischemic stroke occurred in a median of 428 days. Patients who resumed antiplatelets alone (n = 4) had a trend toward more thrombotic events (1.37 versus 0.14 events/patient-year [EPPY]; p = 0.08), including more fatal thrombotic events (0.34 EPPY versus 0.08 EPPY; p = 0.89) compared with those resuming warfarin ± antiplatelet (n = 14). Nonfatal hemorrhage event rates were 0.34 EPPY in the warfarin ± antiplatelet versus 0 EPPY in the antiplatelet-alone group (p = 0.16). No fatal hemorrhagic events occurred.

CONCLUSIONS

Reversal of anticoagulation appears safe after LVAD-associated intracranial hemorrhage, though inadequate reversal was common. Resumption of warfarin ± antiplatelet was associated with fewer fatal and nonfatal thrombotic events compared with antiplatelets alone, though more nonfatal hemorrhage events occurred.

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario

PURPOSE

Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation.

METHODS

A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings.

RESULTS

The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately.

CONCLUSIONS

Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.

Use of Anticoagulation Agents After Traumatic Intracranial Hemorrhage

OBJECTIVE

Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but in the presence of thromboembolic events, the clinician must decide if the benefits outweigh the risks. Currently, no data exist to guide therapy in the acute setting.

METHODS

We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full-dose enoxaparin, or warfarin during their initial hospitalization over a 3-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of ACT, and complications.

RESULTS

A total of 112 patients were identified. The median age and Glasgow Coma Scale score of these patients was 50.5 years and 9.5, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury, including intracranial pressure monitors and/or open surgeries. Fifty-four patients had deep vein thrombosis or pulmonary embolism prior to initiation, and the remaining 20 patients had preexisting conditions or other indications for initiating ACT. The median time from injury to starting ACT was 8 days. Immediate complications occurred in 6 patients; however, none of these patients required a neurosurgical intervention. Delayed complications included progression of acute to chronic subdural hematoma that required intervention in 2 patients. One patient died from delayed hemorrhage.

CONCLUSIONS

For this patient population, the risk of immediate and delayed intracranial hemorrhages from initiating ACT therapy in intracranial injury must be weighed against the morbidity of delaying treatment. Although further studies are needed, our review provides the first rates of complications for this patient population.

Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury

OBJECTIVE

 There is no standard protocol to guide the optimal time to resume anti-clotting agents after traumatic brain injury (TBI) in patients with a continued indication for anticoagulation/antiplatelet therapy (AAT). This study develops baseline data supporting a future prospective cohort study. We predict that there will be significantly decreased adverse events when AAT is started on or after Day 7.

METHODS

 A retrospective chart review of 256 patients was performed. Patients admitted to a level I trauma center in West Texas between January 1, 2009, and December 31, 2012, on anti-clotting agents (specifically acetylsalicylic acid, coumadin, and/or clopidogrel) and who suffered a TBI were included. Patient metrics included admission coagulation studies, type of TBI and treatment, and time to continuation of AAT. Outcomes were assessed using follow-up appointment data. The primary outcome was death (mortality). Secondary outcomes included myocardial infarction, stroke, re-bleed, venous thromboembolism, and pneumonia.

RESULTS

A total of 256 patients met the inclusion criteria. However, only 85 patients on AAT presented for the six-month follow-up. Time to AAT resumption varied from immediate to 31 days. Out of the 85 patients, 32 patients never resumed AAT, 32 patients were restarted on AAT medication in less than seven days, 10 patients restarted medication between seven and 14 days, and 11 patients restarted AAT in more than 14 days. Adverse events occurred most infrequently in the AAT group resuming therapy between seven and 14 days (10%). Adverse events were most prevalent in the AAT group that never resumed therapy (68.8%).

CONCLUSION

 While most studies suggest that the safest time for resuming AAT lies between three and 10 days, our study revealed that adverse events were minimized in patients on AAT between seven and 9.5 days.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan

BACKGROUND

Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile.

MATERIAL AND METHODS

This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup.

RESULTS

The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07).

CONCLUSIONS

We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?

Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.

Recurrent Hemorrhagic Conversion of Ischemic Stroke in a Patient with Mechanical Heart Valve: A Case Report and Literature Review

The authors present a unique case of recurrent stroke, discovered to be secondary to hemorrhagic conversion of microemboli from a mechanical aortic valve despite anticoagulation with Coumadin. The complexity of this case was magnified by the patient’s young age, a mechanical heart valve (MHV), and a need for anticoagulation to maintain MHV patency in a setting of potentially life-threatening intracranial hemorrhage. Anticoagulant and antiplatelet therapy are risk factors for hemorrhagic conversion post-cerebral ischemia; however, the pathophysiology underlying endothelial cell dysfunction causing red blood cell extravasation is an active area of basic and clinical research. The need for randomized clinical trials to aid in the creation of standardized treatment protocol continues to go unmet. Consequently, there is marked variation in therapeutic approaches to treating intracranial hemorrhage in patients with an MHV. Unfortunately, patients with an MHV are considered at high thromboembolic (TE) risk, and these patients are often excluded from clinical trials of acute stroke due to their increased TE potential. The authors feel this case represents an example of endothelial dysfunction secondary to microthrombotic events originating from an MHV, which caused ischemic stroke with hemorrhagic conversion complicated by the need for anticoagulation for an MHV. This case offers a definitive treatment algorithm for a complex clinical dilemma.

Timing of vitamin K antagonist re-initiation following intracranial hemorrhage in mechanical heart valves: Systematic review and meta-analysis

BACKGROUND

While evidence supports resumption of vitamin K antagonists (VKAs) among mechanical heart valve (MHV) patients presenting with anticoagulant-associated intracranial hemorrhage (ICH), ideal timing of resumption is uncertain.

OBJECTIVE

To determine the optimal timing of VKA re-initiation and its associated clinical outcomes.

METHODS

We performed a systematic review and a meta-analysis of studies published from January 1950 to August 2015. We extracted data on the location of initial ICH, use of cranial surgery, presence of atrial fibrillation, MHV type and position, number of MHVs, and timing of VKA resumption. Outcomes including valve thrombosis, thromboembolic events or ICH recurrence were recorded. Meta-regression analysis was conducting with controlling for covariates. We calculated absolute risks, and assessed the effect of anticoagulant resumption timing on ICH recurrence.

RESULTS

23 case-series and case-reports were identified. Overall ICH recurrence was 13% (95% confidence interval [CI], 7%-25%), while valve thrombosis and ischemic strokes occurred at 7% (95% CI, 3%-17%) and 12% (95% CI, 5%-23%) respectively. A trend towards lower ICH recurrence was observed with delayed VKA resumption (slope estimate -0.2154, p=0.10). Recurrence rate ranged from 50% with VKA resumption at 3days to 0% with resumption at 16days.

CONCLUSION

Among patients with MHV, there is inadequate data to suggest an optimal timing of VKA re-initiation following an ICH, though delayed restart appears to be protective against recurrence but is associated with higher risk of thrombosis. Our analysis suggests 4-7days might be an ideal time with least risk of thrombosis or ICH recurrence.

Intracerebral hemorrhage in patients after heart valve replacement

BACKGROUNDS

Although prevention of hematoma enlargement and thromboembolic complications is critically important in acute intracerebral hemorrhage (ICH) patients with prosthetic heart valves, clinical data are scarce. The goal of this study was to elucidate patient characteristics, acute treatments, and the clinical course of them.

METHODS

We investigated a retrospective cohort of consecutive acute ICH patients with prosthetic heart valves. Neurological data, hospital management, hemorrhagic and thromboembolic complications and functional disability/mortality were reviewed.

RESULTS

We identified 38 patients (27 men; 67.9±16.7 years). The median ICH volume was 22.8 ml. The most frequent location was lobar (50%). All patients with mechanical valves (25/25) and 46% of patients with bioprosthetic valves (6/13) were receiving warfarin at the time of hospital admission. The median anticoagulation withholding period was 2 days in 24 patients who ultimately resumed anticoagulation. Hematoma enlargement within 24 h was observed in eight patients and hemorrhagic complications occurred in three patients. Thromboembolic stroke occurred in four patients. At discharge, death had occurred or severe disability was present in 53% of patients (20/38).

CONCLUSIONS

Hematoma enlargement, hemorrhagic complications or thromboembolic stroke occurred in a significant number of patients during hospitalization. ICH was a serious complication among patients with valve replacement.

Anticoagulation Therapy in Traumatic Brain Injury

BACKGROUND

Optimal anticoagulation therapy (AT) in patients with traumatic brain injury (TBI) is a challenging task and proper management is strongly correlated with clinical outcomes. Only limited data are available on AT after TBI and practical decision making is based on the opinion of experts. This review sought to critically assess different therapeutic options using AT and antiplatelet agents in the perioperative period after TBI.

METHODS

A comprehensive review of the literature was performed to summarize relevant data on AT in patients with TBI.

RESULTS

Patients with preinjury AT with TBI require emergent neurosurgical treatment and they are also at high risk of developing thromboembolic complications or hematoma expansion. New oral anticoagulants offer a lower incidence of intracranial hemorrhage compared with warfarin. The rate of intracranial hemorrhage during new oral anticoagulants or heparin therapy is significantly lower than that with vitamin K antagonists.

Anticoagulation dilemma in a high-risk patient with On-X valves

Thromboembolism continues to be a major concern in patients with mechanical heart valves, especially in those with unsatisfactory anticoagulation levels. The new On-X valve (On-X Life Technologies, Austin, TX, USA) has been reported as having unique structural characteristics that offer lower thrombogenicity to the valve. We report a case where the patient received no or minimal systemic anticoagulation after placement of On-X mitral and aortic valves due to development of severe mucosal arterio-venous malformations yet did not show any evidence of thromboembolism. This case report reinforces the findings of recent studies that lower anticoagulation levels may be acceptable in patients with On-X valves and suggests this valve may be particularly useful in those in whom therapeutic levels of anticoagulation cannot be achieved due to increased risk of bleeding.

A multicenter, prospective, observational study of warfarin-associated intracerebral hemorrhage: The SAMURAI-WAICH study

BACKGROUND

Because patients with warfarin-associated intracerebral hemorrhage (WAICH) have a high risk of ongoing bleeding, disability, and death, urgent coagulopathy reversal should be considered. On the other hand, thromboembolism may occur with reversal or withholding of anticoagulant therapy. The current status of acute hemostatic treatments and clinical outcomes in WAICH patients was investigated.

METHODS

WAICH patients admitted within 3 days of onset were prospectively enrolled in 10 stroke centers. Thromboembolic and hemorrhagic complications and functional outcomes were followed-up for one year.

RESULTS

Of 50 WAICH patients (31 men, 73 ± 9 years old) enrolled, all stopped warfarin on admission. Elevated prothrombin time-international normalized ratios (PT-INR) were normalized in 43 (86%). Anticoagulant therapy was resumed with intravenous full-dose unfractionated heparin followed by warfarin in 9 (18%), intravenous low-dose unfractionated heparin followed by warfarin in 14 (28%) and warfarin alone in 14 (28%) at a median of 2.5 (IQR 1.25-9), 4 (2-5.5) and 6 (3-11) days after onset, respectively, after emergent admission. Onset-to-admission time (per 1-hour increase; OR 0.55, 95% CI 0.19-0.84) was inversely associated with hematoma expansion. Anticoagulant therapy was resumed with intravenous full-dose unfractionated heparin in 9 (18%), low-dose heparin in 14 (28%) and warfarin alone in 14 (28%) at a median of 2.5, 4 and 6 days after onset, respectively. During one-year follow-up (n=47), 11 thromboembolic and 6 hemorrhagic complications were documented. Twenty four patients showed unfavorable outcomes, corresponding to a modified Rankin Scale score of 4-6. Thromboembolic complications (OR, 10.62; 95% CI, 1.05-227.85), as well as advanced age (per 1 year; OR, 1.27; 95% CI, 1.10-1.61) and higher National Institutes of Health Stroke Scale (NIHSS) score (per 1 point; OR, 1.24; 95% CI 1.07-1.55), were independently associated with unfavorable outcome.

CONCLUSIONS

PT-INR normalization on admission and early anticoagulant resumption were common in WAICH patients. Thromboembolic complications were independently associated with unfavorable outcome.

Management of anticoagulant-related intracranial hemorrhage: an evidence-based review

The increased use of anticoagulants for the prevention and treatment of thromboembolic diseases has led to a rising incidence of anticoagulant-related intracranial hemorrhage (AICH) in the aging western population. High mortality accompanies this form of hemorrhagic stroke, and significant and debilitating long-term consequences plague survivors. Although management guidelines for such hemorrhages are available for the older generation anticoagulants, they are still lacking for newer agents, which are becoming popular among physicians. Supportive care, including blood pressure control, and reversal of anticoagulation remain the cornerstone of acute management of AICH. Prothrombin complex concentrates are gaining popularity over fresh frozen plasma, and reversal agents for newer anticoagulation agents are being developed. Surgical interventions are options fraught with complications, and are decided on a case-by-case basis. Our current state of understanding of this condition and its management is insufficient. This deficit calls for more population-based studies and therapeutic trials to better evaluate risk factors for, and to prevent and treat AICH.

Postoperative anticoagulation in patients with mechanical heart valves following surgical treatment of subdural hematomas

BACKGROUND

Thromboembolic events and anticoagulation-associated bleeding events represent frequent complications following cardiac mechanical valve replacement. Management guidelines regarding the timing for resuming anticoagulation therapy following a surgically treated subdural hematoma (SDH) in patients with mechanical valves remains to be determined.

OBJECTIVE

To determine optimal anticoagulation management in patients with mechanical heart valves following treatment of SDH.

METHODS

Outcomes were retrospectively reviewed for 12 patients on anticoagulation therapy for thromboembolic prophylaxis for mechanical cardiac valves who underwent surgical intervention for a SDH at the Johns Hopkins Hospital between 1995 and 2010.

RESULTS

The mean age at admission was 71 years. All patients had St. Jude's mechanical heart valves and were receiving anticoagulation therapy. All patients had their anticoagulation reversed with vitamin K and fresh frozen plasma and underwent surgical evacuation. Anticoagulation was withheld for a mean of 14 days upon admission and a mean of 9 days postoperatively. The average length of stay was 19 days. No deaths or thromboembolic events occurred during the hospitalization. Average follow-up time was 50 months, during which two patients had a recurrent SDH. No other associated morbidities occurred during follow-up.

CONCLUSION

Interruptions in anticoagulation therapy for up to 3 weeks pose minimal thromboembolic risk in patients with mechanical heart valves. Close follow-up after discharge is highly recommended, as recurrent hemorrhages can occur several weeks after the resumption of anticoagulation.

Effect of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk

OBJECTIVE

There was no abundance of data on the use of anticoagulant in patients with previous high risk of thromboembolic conditions under a newly developed intracranial hemorrhage in Korean society. The purpose of this study was to evaluate the safety of discontinuance and suggest the proper time period for discontinuance of anticoagulant among these patients.

METHODS

We reviewed the medical records of 19 patients who took anticoagulant because of thromboembolic problems and were admitted to our department with newly developed anticoagulation associated intracranial hemorrhage (AAICH), and stopped taking medicine due to concern of rebleeding from January 2008 to December 2012. Analysis of the incidence of thromboembolic complications and proper withdrawal time of anticoagulant was performed using the Kaplan-Meier method.

RESULTS

Our patients showed high risk for thromboembolic complication. The CHA2DS2-VASc score ranged from two to five. Thromboembolic complication occurred in eight (42.1%) out of 19 patients without restarting anticoagulant since the initial hemorrhage. Among them, three patients (37.5%) died from direct thromboembolic complications. Mean time to outbreak of thromboembolic complication was 21.38±14.89 days (range, 8-56 days). The probability of thromboembolic complications at 7, 14, and 30 days since cessation of anticoagulation was 0.00, 10.53, and 38.49%, respectively.

CONCLUSION

Short term discontinuance of anticoagulant within seven days in patients with AAICH who are at high embolic risk (CHA2DS2-VASc score >2) appears to be relatively safe in Korean people. However, prolonged cessation (more than seven days) may result in increased incidence of catastrophic thromboembolic complications.

Treatment of acute subdural hematoma

OPINION STATEMENT

Clinical presentation, neurologic condition, and imaging findings are the key components in establishing a treatment plan for acute SDH. Location and size of the SDH and presence of midline shift can rapidly be determined by computed tomography of the head. Immediate laboratory work up must include PT, PTT, INR, and platelet count. Presence of a coagulopathy or bleeding diathesis requires immediate reversal and treatment with the appropriate agent(s), in order to lessen the risk of hematoma expansion. Reversal protocols used are similar to those for intracerebral hemorrhage, with institutional variations. Immediate neurosurgical evaluation is sought in order to determine whether the SDH warrants surgical evacuation. Urgent or emergent surgical evacuation of a SDH is largely influenced by neurologic examination, imaging characteristics, and presence of mass effect or elevated intracranial pressure. Generally, evacuation of an acute SDH is recommended if the clot thickness exceeds 10 mm or the midline shift is greater than 5 mm, regardless of the neurologic condition. In patients with patients with an acute SDH with clot thickness <10 mm and midline shift <5 mm, specific considerations of neurologic findings and clinical circumstances will be of importance. In addition, consideration will be given as to whether an individual patient is likely to benefit from surgery. For an acute SDH, evacuation by craniotomy or craniectomy is preferred over burr holes based on available data. Postoperative care includes monitoring of resolution of pneumocephalus, mobilization and drain removal, and monitoring for signs of SDH reaccumulation. Medical considerations include seizure prophylaxis and management as well as management and resumption of antithrombotic and anticoagulant medication.

Anticoagulation for prosthetic valves

Implantation of prosthetic valve requires consideration for anticoagulation. The current guideline recommends warfarin on all mechanical valves. Dabigatran is the new generation anticoagulation medication which is taken orally and does not require frequent monitoring. This drug is approved for treatment for atrial fibrillation and venous thromboembolism, but the latest large trial showed that this drug increases adverse events when used for mechanical valve anticoagulation. On-X valve is the new generation mechanical valve which is considered to require less anticoagulation due to its flow dynamics. The latest study showed that lower anticoagulation level lowers the incidence of bleeding, while the risk of thromboembolism and thrombosis remained the same. Anticoagulation poses dilemma in cases such as pregnancy and major bleeding event. During pregnancy, warfarin can be continued throughout pregnancy and switched to heparin derivative during 6-12 weeks and >36 weeks of gestation. Warfarin can be safely started after 1-2 weeks of discontinuation following major bleeding episode.

Intracerebral hemorrhage: new challenges and steps forward

Intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality. With the aging population, increased use of anticoagulants, and changing racial and ethnic landscape of the United States, the incidence of ICH will increase over the next decade. Improvements in preventative strategies to treat hypertension and atrial fibrillation are necessary to change the trajectory of this increase. Advances in the understanding of ICH at the vascular and molecular level may pave the way to new treatment options. This article discusses the epidemiology, pathophysiology, and current treatment options for patients with ICH. Differences in outcome and treatment between patients taking and not taking anticoagulant therapies are considered.

Intracerebral hemorrhage in patients receiving oral anticoagulation therapy

Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.

When should you restart anticoagulation in patients who suffer an intracranial bleed who also have a prosthetic valve?

A best evidence topic in cardiac surgery was written according to the structured protocol. The question addressed was about the best time to restart anticoagulation in patients with intracranial bleed with a prosthetic valve in situ. This difficult clinical decision has to balance the risk of thromboembolism during the period that the anticoagulation was reversed and later withheld vs the risk of haematoma expansion or rebleed if the anticoagulation was started early. Altogether, more than 80 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. There were two prospective studies and eight retrospective studies. There were no randomized controlled trials on this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Seven studies reported the strategy of reversal of anticoagulation with vitamin K, fresh frozen plasma or prothrombin concentrate. The emphasis was on prompt initial reversal of anticoagulation; however, the best agent for reversal was not defined. Four studies dealt exclusively with intracranial bleed in patients with prosthetic valve in situ. The remaining six studies on intracranial bleed had only a subset of patients with a prosthetic valve in situ. The anticoagulation was restarted with heparin and later switched to oral anticoagulant. Thromboembolic events during the period of reversal and cessation of anticoagulants were low (5%) as was the incidence of rebleed or haematoma expansion (0.5%). We conclude that anticoagulation can safely be withheld for a short period, up to 7-14 days in a patient with intracranial bleed with a very low probability of thromboembolic phenomenon. In patients with prosthetic valves, in situ anticoagulation in the form of heparin can safely be restarted as early as 3 days and switched to oral anticoagulation in the form of warfarin at 7 days without major concerns of bleeding.

On the value of routine prothrombin time screening in elective neurosurgical procedures

Object

The authors performed a study to evaluate whether preoperative assessment of prothrombin time (PT) is mandatory in patients undergoing routinely planned neurosurgical procedures.

Methods

The charts of all patients admitted to general wards of the authors' department for routinely planned surgery (excluding trauma and ICU patients) between 2006 and 2010 were retrospectively reviewed. The authors assessed preoperative PT and the clinical courses of all patients, with special consideration for patients receiving coagulation factor substitution. All cases involving hemorrhagic complications were analyzed in detail with regard to pre- and postoperative PT abnormalities. Prothrombin time was expressed as the international normalized ratio, and values greater than 1.28 were regarded as elevated.

Results

Clinical courses and PT values of 4310 patients were reviewed. Of these, 33 patients (0.7%) suffered hemorrhagic complications requiring repeat surgery. Thirty-one patients (94%) had a normal PT before the initial operation, while 2 patients had slightly elevated PT values of 1.33 and 1.65, which were anticipated based on the patient's history. In the latter 2 cases, surgery was performed without prior correction of PT. Preoperatively, PT was elevated in 78 patients (1.8%). In 73 (93.6%) of the 78 patients, the PT elevation was expected and explained by each patient's medical history. In only 5 (0.1%) of 4310 patients did we find an unexpected PT elevation (mean 1.53, range 1.37–1.74). All 5 patients underwent surgery without complications, while 2 had received coagulation factor substitution preoperatively, as requested by the surgeon, because of an estimated risk of bleeding complications. None of the 5 patients received coagulation factor substitution postoperatively, and later detailed laboratory studies ruled out single coagulation factor deficiencies. There was no statistically significant association between preoperatively elevated PT levels and the occurrence of hemorrhagic complications (p = 0.12). Before the second procedure but not before the initial operation, 4 (12%) of the 33 patients had elevated PT.

Conclusions

The findings suggest that the value of preoperative PT testing is limited in patients in whom a normal history can be ascertained. Close postoperative PT control is necessary in every neurosurgical patient, and better tests need to be developed to identify patients who are prone to hemorrhagic complications.

Management of intracranial hemorrhage in a child with a left ventricular assist device

Pediatric patients bridged to heart transplant with LVADs require chronic anticoagulation and are at increased risk of hemorrhagic complications, including intracranial hemorrhage. In this population, intracranial hemorrhage is often fatal. We report a case of successful management of a five-yr-old-boy with DCM on an LVAD who developed a subdural hematoma. We initially chose medical management, weighing the patient's high risk of thromboembolism from anticoagulation reversal against the risk of his chronic subdural hematoma. When head CT showed expansion of the hemorrhage with increasing midline shift, we chose prompt surgical evacuation of the hematoma with partial reversal of anticoagulation, given the increased risk of acute deterioration. The patient ultimately received an orthotopic heart transplant and was discharged with no permanent neurological complications. This represents a case of a pediatric patient on an LVAD who survived a potentially fatal subdural hematoma and was successfully bridged to cardiac transplantation.

Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage

Introduction

Therapeutic anticoagulation is an important treatment of thromboembolic complications, such as DVT, PE, and blunt cerebrovascular injury. Traumatic intracranial hemorrhage has traditionally been considered to be a contraindication to anticoagulation.

Hypothesis

Therapeutic anticoagulation can be safely accomplished in select patients with traumatic intracranial hemorrhage.

Methods

Patients who developed thromboembolic complications of DVT, PE, or blunt cerebrovascular injury were stratified according to mode of treatment. Patients who underwent therapeutic anticoagulation with a heparin infusion or enoxaparin (1 mg/kg BID) were evaluated for neurologic deterioration or hemorrhage extension by CT scan.

Results

There were 42 patients with a traumatic intracranial hemorrhage that subsequently developed a thrombotic complication. Thirty-five patients developed a DVT or PE. Blunt cerebrovascular injury was diagnosed in four patients. 26 patients received therapeutic anticoagulation, which was initiated an average of 13 days after injury. 96% of patients had no extension of the hemorrhage after anticoagulation was started. The degree of hemorrhagic extension in the remaining patient was minimal and was not felt to affect the clinical course.

Conclusion

Therapeutic anticoagulation can be accomplished in select patients with intracranial hemorrhage, although close monitoring with serial CT scans is necessary to demonstrate stability of the hemorrhagic focus.

Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding

Management of warfarin-induced major bleeding in patients with mechanical heart valves is challenging. There is vast controversy and confusion in the type of treatment required to reverse anticoagulation and stop bleeding as well as the ideal time to restart warfarin therapy safely without recurrence of bleeding and/or thromboembolism. Presently, the treatments available to reverse warfarin-induced bleeding are vitamin K, fresh frozen plasma, prothrombin complex concentrates and recombinant activated factor VIIa. Currently, vitamin K and fresh frozen plasma are the recommended treatments in patients with mechanical heart valves and warfarin-induced major bleeding. The safe use of prothrombin complex concentrates and recombinant activated factor VIIa in patients with mechanical heart valves is controversial and needs well-designed clinical studies. With regard to restarting anticoagulation in patients with warfarin-induced major bleeding and mechanical heart valves, the safe period varies from 7-14 d after the onset of bleeding for patients with intracranial bleed and 48-72 h for patients with extra-cranial bleed. In this review article, we present relevant literature about these controversies and suggest recommendations for management of patients with warfarin-induced bleeding and a mechanical heart valve. Furthermore, there is an urgent need for separate specific guidelines from major associations/ professional societies with regard to mechanical heart valves and warfarin-induced bleeding.

Survey of neurosurgical management of central nervous system hemorrhage in patients receiving anticoagulation therapy: current practice is highly variable and may be suboptimal

BACKGROUND

Patients with central nervous system (CNS) hemorrhage who receive anticoagulation (AC) therapy are at high risk for progressive or recurrent hemorrhagic and thromboembolic (TE) events. The authors conducted a survey at the 2010 American Association of Neurological Surgeons (AANS) annual meeting to determine how these patients are currently being managed by neurosurgeons.

METHODS

During plenary session III at the 2010 AANS annual meeting, the audience was presented with an illustrative case and surveyed with an audience response system. The number choosing each response as well as data regarding the level of training of meeting registrants were provided to the authors by the AANS.

RESULTS

Approximately 10% of all meeting registrants responded to the questions, 65% of whom were consultant neurosurgeons. The responses showed that 47.7% of respondents face dilemmas regarding AC restart time and intensity at least once per week. The most commonly selected AC restart time was 1 month after the index hemorrhage (43.5%); 8.0% indicated they would not restart AC. In making management decisions in these patients, 59.4% of respondents indicated that they relied predominantly on their own intuition or past experience.

CONCLUSIONS

This study is the first to describe how patients with CNS hemorrhage who receive AC therapy are currently being managed by clinicians. An apparent neurosurgical preference to avoid hemorrhagic complications is at odds with a suggested early risk for TE. These data suggest that the neurosurgical management of patients with CNS hemorrhage who receive AC therapy is an area that could benefit from consensus-based practice guidelines and an organized effort at knowledge translation and mobilization.

[Intracerebral hemorrhage in anticoagulated patients: what do we do afterwards?]

INTRODUCTION

The management of antithrombotic therapy after intracerebral hemorrhage (ICH) in anticoagulated patients is not well defined. We analyzed the risks and benefits of antiplatelet therapy (AG) against the resumption of anticoagulation with vitamin K antagonists (AVK) in a series of patients.

MATERIAL AND METHODS

Retrospective study of ICH in anticoagulated patients. We registered demographic data, history of hypertension (HT), time of follow-up and new cerebral vascular events (ICH, stroke [IC]).

RESULTS

We evaluated 88 patients, mean age 69±9 years, 50% men, 73% hypertensive. During the acute phase 18 patients died and the follow-up was lost in 31. Of the remaining (n=39), AVKs were resumed in 25 and changed to AG in 14. Comparing the characteristics of both groups, the anticoagulated group was younger (P=.005) and the embolic sources were more often of higher risk (P=.003). After an average follow-up of 54±31 months, the distribution of events was: IC (AVKs 8%, AG 14.3%, P=.6), ICH (AVKs 24%, AG 7.1%, P=.38), IC or ICH (AVKs 32%, AG 21.4%, P=.48) and death (AVKs 29%, AG 7.1%, P=.21). This trend of increased risk of new events in patients with AVKs was confirmed by Kaplan-Meier curves, although without statistical differences.

CONCLUSIONS

Restarting AVK treatment after ICH in anticoagulated patients could increase the risk of new bleeding events and mortality. Prospective studies are needed to define a better and appropriate antithrombotic therapy after ICH related with anticoagulation.