Does prior antiplatelet therapy influence hematoma volume and hematoma growth following intracerebral hemorrhage? Results from a prospective study and a meta-analysis

Safety and efficacy of desmopressin (DDAVP) in preventing hematoma expansion in intracranial hemorrhage associated with antiplatelet drugs use: A systematic review and metaanalysis

INTRODUCTION

One of the most serious complications associated with antiplatelet agents is antiplatelet-associated intracranial hemorrhage (AA-ICH). Desmopressin is a synthetic antidiuretic hormone (ADH) analog. It has been linked to improving patient outcomes in antiplatelet-induced intracranial hemorrhage. The secondary outcomes included the incidence of thrombotic complications and neurological outcomes.

METHODS

A systematic search was conducted on three databases (PubMed, Cochrane, and ClinicalTrials.gov) to find eligible literature that compares desmopressin (DDAVP) versus controls in patients with AA-ICH. The Mantel-Haenszel statistic was used to determine an overall effect estimate for each outcome by calculating the risk ratios and 95% confidence intervals (CI). Heterogeneity was measured using the I2 test. The risk of bias in studies was calculated using the New Castle Ottowa Scale.

RESULTS

Five studies were included in the analysis with a total of 598 patients. DDAVP was associated with a nonsignificant decrease in the risk of hematoma expansion (RR = .8, 95% CI,.51-1.24; p = .31, I2 = 44%). It was also associated with a non-significant decrease in the risk of thrombotic events (RR,.83; 95% CI,.25-2.76; p = .76, I2 = 30%). However, patients in the DDAVP group demonstrated a significant increase in the risk of poor neurological outcomes (RR, 1.31; 95% CI, 1.07-1.61; p = .01, I2 = 0%). The risk of bias assessment showed a moderate to low level of risk.

CONCLUSION

DDAVP was associated with a nonsignificant decrease in hematoma expansion and thrombotic events. However, it was also associated with a significantly poor neurological outcome in the patients. Thus, until more robust clinical trials are conducted, the use of DDAVP should be considered on a case-to-case basis.

Hematoma expansion in intracerebral hemorrhage - the right target?

BACKGROUND

The avoidance of hematoma expansion is the most important therapeutic goal during acute care of patients with intracerebral hemorrhage. Hematoma expansion occurs in up to 20-40% of patients and leads to poorer patient outcome in one of the most severe sub-types of stroke.

MAIN TEXT

At current, randomized controlled trials have failed to provide evidence for interventions that effectively improve functional outcome in patients with intracerebral hemorrhage. Hence, hematoma expansion may serve as important surrogate target that appears causally linked with a poorer prognosis. Therefore, reduction of hematoma expansion rates will eventually translate to improved patient outcome overall. Recent years have shed light on the importance of early and aggressive treatment in order to reduce the risk for hematoma expansion in these patients. Time measures and imaging markers have been identified that may allow patient selection at very high risk for hematoma expansion.

CONCLUSIONS

Refinements in patient selection may increase chance for randomized trials to show true benefit. Therefore, this current review article will critically evaluate and discuss available evidence associated with hematoma expansion in patients with intracerebral hemorrhage.

Does dual antiplatelet therapy increase the risk of haematoma enlargement in the acute stage? A retrospective study of the use of stent-assisted coiling versus coiling alone or balloon-assisted coiling for the treatment of ruptured intracranial aneurysms combined with intracranial haematoma

This study aims to identify the efficacy and safety of stent-assisted coiling (SAC) treatment of ruptured intracranial aneurysms (RIAs) combined with intracranial haematoma (ICH) compared to coiling alone or balloon-assisted coiling (non-SAC). A retrospective analysis of 54 consecutive patients receiving endovascular therapy from 2014 to 2020 was performed. The data collected included baseline characteristics, angiographic results, perioperative complications, immediate aneurysm occlusion, clinical outcomes, follow-up at discharge and after 6 months, hospitalisation costs, and inpatient length of stay. Patients were categorised into the SAC group and the non-SAC group. Univariate and multivariate logistic regression analyses were used to identify risk factors related to clinical outcomes. Of the 54 patients harbouring RIAs with ICH, 22 (40.74%) and 32 (59.26%) patients were subject to SAC and non-SAC treatments, respectively. Postoperative rebleeding (1 [4.5%] and 3 [9.3%] in SAC and non-SAC groups, respectively, p > 0.05) and Hunt-Hess grade (IV-V) lesions (13.6% vs. 40.6%, p = 0.067) did not differ between the two groups. In total, 10 (45.5%) patients treated with SAC received a Fisher scale score of 0-3 compared with 6 (18.8%) patients treated with non-SAC methods (p = 0.035). Compared with the non-SAC group (7/21.9%), the rate of wide-necked aneurysms was increased in the SAC group (11/50%) (p = 0.031). No differences in poor outcomes (mRS > 2) were noted between the SAC and non-SAC groups (p > 0.05). Multivariate analysis revealed that ischaemic complication events (p = 0.016) represent the only independent risk factor for adverse outcomes, and a trend towards unfavourable clinical outcomes was noted for patients who smoke (p = 0.087). SAC is a safe and efficient treatment for RIAs combined with ICH when dual antiplatelet therapy (DAPT) is used in the perioperative period. In addition, SAC should be preferentially used in wide-neck RIAs. Ischaemic complications are a risk factor for poor clinical outcomes. Given the small sample size and retrospective bias of this study, these findings should be further verified in a study with a larger sample size or a randomised controlled trial (RCT).

Noncontrast Computed Tomography Markers Associated with Hematoma Expansion: Analysis of a Multicenter Retrospective Study

BACKGROUND

Hematoma expansion (HE) is a significant predictor of poor outcomes in patients with intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) markers in ICH are promising predictors of HE. We aimed to determine the association of the NCCT markers with HE by using different temporal HE definitions.

METHODS

We utilized Risa-MIS-ICH trial data (risk stratification and minimally invasive surgery in acute intracerebral hemorrhage). We defined four HE types based on the time to baseline CT (BCT) and the time to follow-up CT (FCT). Hematoma volume was measured by software with a semi-automatic edge detection tool. HE was defined as a follow-up CT hematoma volume increase of >6 mL or a 33% hematoma volume increase relative to the baseline CT. Multivariable regression analyses were used to determine the HE parameters. The prediction potential of indicators for HE was evaluated using receiver-operating characteristic analysis.

RESULTS

The study enrolled 158 patients in total. The time to baseline CT was independently associated with HE in one type (odds ratio (OR) 0.234, 95% confidence interval (CI) 0.077-0.712, p = 0.011), and the blend sign was independently associated with HE in two types (OR, 6.203-6.985, both p < 0.05). Heterogeneous density was independently associated with HE in all types (OR, 6.465-88.445, all p < 0.05) and was the optimal type for prediction, with an area under the curve of 0.674 (p = 0.004), a sensitivity of 38.9%, and specificity of 96.0%.

CONCLUSION

In specific subtypes, the time to baseline CT, blend sign, and heterogeneous density were independently associated with HE. The association between NCCT markers and HE is influenced by the temporal definition of HE. Heterogeneous density is a stable and robust predictor of HE in different subtypes of hematoma expansion.

Early Antiplatelet Resumption and the Risks of Major Bleeding After Intracerebral Hemorrhage

BACKGROUND

The appropriate timing of resuming antithrombotic therapy after intracerebral hemorrhage (ICH) remains unclear. The aim of this study was to compare the risks of major bleeding between early and late antiplatelet resumption in ICH survivors.

METHODS

Between 2008 and 2017, ICH patients were available in the National Health Insurance Research Database. Patients with a medication possession ratio of antiplatelet treatment ≥50% before ICH and after antiplatelet resumption were screened. We excluded patients with atrial fibrillation, heart failure, under anticoagulant or hemodialysis treatment, and developed cerebrovascular events or died before antiplatelet resumption. Finally, 1584 eligible patients were divided into EARLY (≤30 days) and LATE groups (31-365 days after the index ICH) based on the timing of antiplatelet resumption. Patients were followed until the occurrence of a clinical outcome, end of 1-year follow-up, death, or until December 31, 2018. The primary outcome was recurrent ICH. The secondary outcomes included all-cause mortality, major hemorrhagic events, major occlusive vascular events, and ischemic stroke. Cox proportional hazard model after matching was used for comparison between the 2 groups.

RESULTS

Both the EARLY and LATE groups had a similar risk of 1-year recurrent ICH (EARLY versus LATE: 3.12% versus 3.27%; adjusted hazard ratio [AHR], 0.967 [95% CI, 0.522-1.791]) after matching. Both groups also had a similar risk of each secondary outcome at 1-year follow-up. Subgroup analyses disclosed early antiplatelet resumption in the patients without prior cerebrovascular disease were associated with lower risks of all-cause mortality (AHR, 0.199 [95% CI, 0.054-0.739]) and major hemorrhagic events (AHR, 0.090 [95% CI, 0.010-0.797]), while early antiplatelet resumption in the patients with chronic kidney disease were associated with a lower risk of ischemic stroke (AHR, 0.065 [95% CI, 0.012-0.364]).

CONCLUSIONS

Early resumption of antiplatelet was as safe as delayed antiplatelet resumption in ICH patients. Besides, those without prior cerebrovascular disease or with chronic kidney disease may benefit more from early antiplatelet resumption.

Intracerebral haemorrhage volume, haematoma expansion and 3-month outcomes in patients on antiplatelets. A systematic review and meta-analysis

Aims

We assessed the association of prior antiplatelet therapy (APT) at onset of intracerebral haemorrhage (ICH) with haematoma characteristics and outcome.

Methods

We performed a systematic review and meta-analysis of studies comparing ICH outcomes of patients on APT (APT-ICH) with patients not taking APT (non-APT-ICH). Primary outcomes were haematoma volume (mean difference and 95% CI), haematoma expansion (HE), in-hospital 3-month mortality rates and good functional outcome (modified Rankin Scale score 0-2). We provide odds ratios (ORs) from random effects models and subgroup analyses for haematoma expansion and short-term mortality rates.

Results

We included 23 of 1551 studies on 30,949 patients with APT-ICH and 62,018 with non-APT-ICH. Patients on APT were older (Δmean 6.27 years, 95% CI 5.44-7.10), had larger haematoma volume (Δmean 5.74 mL, 95% CI 1.93-9.54), higher short-term mortality rates (OR 1.44, 95% CI 1.14-1.82), 3-month mortality rates (OR 1.58, 95% CI 1.14-2.19) and lower probability of good functional outcome (OR 0.61, 95% CI 0.49-0.77). While there was no difference in HE in the overall analysis (OR 1.32, 95% CI 0.85-2.06), HE occurred more frequently when assessed within 24 h (OR 2.58, 95% CI 1.18-5.67). We found insufficient data for comparison of single versus dual APT-ICH. Heterogeneity was substantial amongst studies.

Discussion

APT is associated with larger baseline haematoma volume, early (<24 h) haematoma expansion, mortality rates and morbidity in patients with ICH. Data on differences in single and dual APT-ICH are scarce and warrant further investigation. New treatment options for APT-ICH are urgently needed.

Hyperacute prediction of functional outcome in spontaneous intracerebral haemorrhage: systematic review and meta-analysis

Purpose

To describe the association between factors routinely available in hyperacute care of spontaneous intracerebral haemorrhage (ICH) patients and functional outcome.

Methods

We searched Medline, Embase and CINAHL in February 2020 for original studies reporting associations between markers available within six hours of arrival in hospital and modified Rankin Scale (mRS) at least 6 weeks post-ICH. A random-effects meta-analysis was performed where three or more studies were included.

Findings

Thirty studies were included describing 40 markers. Ten markers underwent meta-analysis and age (OR = 1.06; 95%CI = 1.05 to 1.06; p < 0.001), pre-morbid dependence (mRS, OR = 1.73; 95%CI = 1.52 to 1.96; p < 0.001), level of consciousness (Glasgow Coma Scale, OR = 0.82; 95%CI = 0.76 to 0.88; p < 0.001), stroke severity (National Institutes of Health Stroke Scale, OR=1.19; 95%CI = 1.13 to 1.25; p < 0.001), haematoma volume (OR = 1.12; 95%CI=1.07 to 1.16; p < 0.001), intraventricular haemorrhage (OR = 2.05; 95%CI = 1.68 to 2.51; p < 0.001) and deep (vs. lobar) location (OR = 2.64; 95%CI = 1.65 to 4.24; p < 0.001) were predictive of outcome but systolic blood pressure, CT hypodensities and infratentorial location were not. Of the remaining markers, sex, medical history (diabetes, hypertension, prior stroke), prior statin, prior antiplatelet, admission blood results (glucose, cholesterol, estimated glomerular filtration rate) and other imaging features (midline shift, spot sign, sedimentation level, irregular haematoma shape, ultraearly haematoma growth, Graeb score and onset to CT time) were associated with outcome.

Conclusion

Multiple demographic, pre-morbid, clinical, imaging and laboratory factors should all be considered when prognosticating in hyperacute ICH. Incorporating these in to accurate and precise models will help to ensure appropriate levels of care for individual patients.

The role of monitoring platelet function perioperatively and platelet transfusion for operated spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy: A case report

Introduction and importance

Spontaneous intracerebral hemorrhage (SICH) with long-term oral antiplatelet therapy (LOAPT) is known as a dilemma in balancing the risk of postoperative rebleeding and ischemic events because of confused coagulation function. We herein describe a report of perioperative management of spontaneous intracerebral hemorrhage patient on long-term oral antiplatelet therapy.

Case presentation

A 42-year-old male patient on long-term oral antiplatelet therapy presented with coma, and he was diagnosed with spontaneous intracerebral hemorrhage. Considering the patient's clinical condition, despite the thromboelastography suggested that the inhibition of platelet function was high preoperatively, an emergency craniectomy were underwent. After platelet transfusion during surgery and taking control of the clotting and platelet function postoperatively, the patient was stable without rebleeding and new ischemic events in perioperative period and recovered satisfactorily.

Clinical discussion

Rare studies have provided evidence for managing operated spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet therapy, and whether platelet transfusion is recommended was controversial. In this case, we presented monitoring and taking control of clotting and platelet function postoperatively would help in preventing rebleeding and ischemic events in such patients; moreover, platelet transfusion may quickly and safely reverse platelet dysfunction for emergency surgery. This case was the first to report platelet function and coagulation function management in spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy.

Conclusion

Monitoring and maintaining coagulation and platelet function perioperatively are essential to balance the risk of postoperative rebleeding and ischemic events.

•

Spontaneous intracerebral hemorrhage with antiplatelet therapy is known as a dilemma in postoperative management.

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Antiplatelet therapy may not be the absolute contraindication for surgery in the severe spontaneous intracerebral hemorrhage.

•

It is essential to monitor and take control of platelet function in postoperative patients with antiplatelet therapy.

Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review

Background

Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population.

Methods

A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed.

Results

The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage.

Conclusion

Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.

Aspirin does not affect hematoma growth in severe spontaneous intracranial hematoma

Hematoma growth (HG) affects the prognosis of patients with spontaneous intracranial hematoma (ICH), but there is still a lack of evidence about the effects of aspirin (acetylsalicylic acid, ASA) on HG in patients with severe ICH. This study retrospectively analyzed patients with severe ICH who met the inclusion and exclusion criteria in Beijing Tiantan Hospital, Capital Medical University, between January 1, 2015, and July 31, 2019. Severe ICH patients were divided into ASA group and nASA groups according to ASA usage, and the incidence of HG between the groups was compared. Univariate analysis was performed by the Mann-Whitney U test, chi-square test, or Fisher exact test. Multivariate logistic regression analysis was used to analyze the impact of ASA on HG and to screen for risk factors of HG. In total, 221 patients with severe ICH were consecutively enrolled in this study. There were 72 (32.6%) patients in the ASA group and 149 patients in the nASA group. Although the incidence of HG in the nASA group was higher than that in the ASA group (34.9% VS 22.2%, p = 0.056), ASA did not significantly affect the occurrence of HG (p = 0.285) after adjusting for initial hematoma volume, high blood pressure at admission, coronary heart disease, and GCS at admission. In addition, we found that high blood pressure at admission was a risk factor for HG. Prior ASA does not increase the incidence of HG in severe ICH patients, and high blood pressure at admission is a risk factor for HG.

Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y₁₂ inhibitor is an established therapy for a broad spectrum of patients with cardiovascular disease. The ischemic benefit of DAPT is partially offset by its increased bleeding risk, with intracranial hemorrhage (ICH) being the most serious complication. Although uncommon (0.2%-0.3% annually), its cumulative burden can be substantial given the number of patients afflicted by cardiovascular disease worldwide. Patients with a history of stroke or transient ischemic attack harbor a particularly high risk for ICH when treated with DAPT. Prediction rules may assist clinicians when weighing the risk/benefit ratio of prescribing DAPT for patients with stroke/transient ischemic attack in the nonacute, ambulatory setting. Currently, there are no reversal agents that can rapidly and effectively reverse the effect of P2Y₁₂ inhibitors in routine practice, although a reversal agent for ticagrelor is under clinical investigation.

Effects of Prior Antiplatelet Therapy on Mortality, Functional Outcome, and Hematoma Expansion in Intracerebral Hemorrhage: An Updated Systematic Review and Meta-Analysis of Cohort Studies

Background and Objective: Antiplatelet therapy (APT) is widely used and believed to be associated with increased poor prognosis by promoting bleeding in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to determine whether prior APT is associated with mortality, functional outcome, and hematoma expansion in ICH patients. Methods: The PubMed, Embase, and Web of Science databases were searched for relevant published studies up to December 11, 2020. Univariate and multivariable adjusted odds ratios (ORs) were pooled using a random effects model. Cochran's chi-squared test (Cochran's Q), the I 2 statistic, and meta-regression analysis were used to evaluate the heterogeneity. Meta-regression models were developed to explore sources of heterogeneity. Funnel plots were used to detect publication bias. A trim-and-fill method was performed to identify possible asymmetry and assess the robustness of the conclusions. Results: Thirty-one studies fulfilled the inclusion criteria and exhibited a moderate risk of bias. Prior APT users with intracerebral hemorrhage (ICH) had a slightly increased mortality in both univariate analyses [odds ratio (OR) 1.39, 95% CI 1.24-1.56] and multivariable adjusted analyses (OR 1.41, 95% CI 1.21-1.64). The meta-regression indicated that for each additional day of assessment time, the adjusted OR for the mortality of APT patients decreased by 0.0089 (95% CI: -0.0164 to -0.0015; P = 0.0192) compared to that of non-APT patients. However, prior APT had no effects on poor function outcome (pooled univariate OR: 0.99, 95% CI 0.59-1.66; pooled multivariable adjusted OR: 0.93, 95% CI 0.87-1.07) or hematoma growth (pooled univariate OR: 1.23, 95% CI 0.40-3.74, pooled multivariable adjusted OR: 0.94, 95% CI 0.24-3.60). Conclusions: Prior APT was not associated with hematoma expansion or functional outcomes, but there was modestly increased mortality in prior APT patients. Higher mortality of prior APT patients was related to the strong influence of prior APT use on early mortality. Systematic Review Registration:PROSPERO Identifier [CRD42020215243].

Prior Antithrombotic Therapy is Associated with Increased Risk of Death in Patients with Intracerebral Hemorrhage: Findings from the Chinese Stroke Center Alliance (CSCA) Study

The association of preceding antithrombotic therapy with outcomes of patients with intracerebral hemorrhage (ICH) has not been well clarified. We investigated the characteristics and associations of prior antithrombotic therapy (oral anticoagulants, antiplatelet therapy or both) in outcomes of in-hospital patients with ICH. Data were derived from the Chinese Stroke Center Alliance (CSCA) database. Enrolled patients were categorized by the different types of preceding antithrombotic therapy: antiplatelet therapy (APT), oral coagulants (OAs), both OAs and APT use and no-antithrombotic therapy (no-ATT). Among 85705 patients enrolled, 4969 (5.8%), 720 (0.8%), 905 (1.1%) and 79111 (92.3%) patients were on APT, OAs, both OAs and APT, and non-ATT respectively prior to their admission. Crude in-hospital death was 149(3.0%), 41(5.7%), 46(5.1%) and 1781(2.3%) in APT, OAs, both OAs and APT, and non-ATT groups, respectively (P<0.0001). Multivariate analysis revealed that patients in prior OAs (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.18-3.21; P=0.0091) and both OAs and APT groups (aOR 1.92, 95% CI 1.17-3.15, P=0.0094) were associated with an increased risk of in-hospital mortality compared with the non-ATT group, but not in those who were on APT (aOR 1.12, 95% 0.93-1.36, P=0.2372). In the subgroup analysis, a stronger association between prior OAs and in-hospital death was found among patients who were older ≥ 65 years (P for interaction is 0.0382). In this nationwide prospective study, prior OAs and concomitant use of OAs and APT but not prior ATP were associated with increased odds of in-hospital mortality compared with ICH patients who were on no-ATT.

Defining Minor Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

The minor stroke concept has not been analyzed in intracerebral hemorrhage (ICH) patients. Our purpose was to determine the optimal cut point on the NIH Stroke Scale (NIHSS) for defining a minor ICH (mICH) in patients with primary ICH.

METHODS

An ICH was considered minor if associated with a favorable 3-month outcome (modified Rankin Scale score ≤2). For supratentorial ICH, the discovery cohort consisted of 478 patients prospectively admitted at University Hospital del Mar. Association between NIHSS at admission and 3-month outcome was evaluated with area under the curve-receiver operating characteristics (AUC-ROC) and Youden's index to identify the optimal NIHSS cutoff point to define mICH. External validation was performed in a cohort of 242 supratentorial ICH patients from University Hospital Sant Pau. For infratentorial location, patients from both hospitals (n = 85) were analyzed together.

RESULTS

The best -NIHSS cutoff point defining supratentorial-mICH was 6 (AUC-ROC = 0.815 [0.774-0.857] in the discovery cohort and AUC-ROC = 0.819 [0.756-0.882] in the external validation cohort). For infratentorial ICH, the best cutoff point was 4 (AUC-ROC = 0.771 [0.664-0.877]). Using these cutoff points, 40.5% of all primary ICH cases were mICH. Of these, 70.2% were living independently at 3-month follow-up (72% for supratentorial ICH and 56.1% for infratentorial ICH) and 6.5% had died (5.3% for supratentorial ICH, and 14.6% for infratentorial ICH). For patients identified as non-mICH, good 3-month outcome was observed in 11.3% of cases; mortality was 51%.

CONCLUSIONS

The definition of mICH using the NIHSS cutoff point of 6 for supratentorial ICH and 4 for infratentorial ICH is useful to identify good outcome in ICH patients.

Outcomes in Antiplatelet-Associated Intracerebral Hemorrhage in the TICH-2 Randomized Controlled Trial

Background

Antiplatelet therapy increases the risk of hematoma expansion in intracerebral hemorrhage (ICH) while the effect on functional outcome is uncertain.

Methods and Results

This is an exploratory analysis of the TICH‐2 (Tranexamic Acid in Intracerebral Hemorrhage‐2) double‐blind, randomized, placebo‐controlled trial, which studied the efficacy of tranexamic acid in patients with spontaneous ICH within 8 hours of onset. Multivariable logistic regression and ordinal regression were performed to explore the relationship between pre‐ICH antiplatelet therapy, and 24‐hour hematoma expansion and day 90 modified Rankin Scale score, as well as the effect of tranexamic acid. Of 2325 patients, 611 (26.3%) had pre‐ICH antiplatelet therapy. They were older (mean age, 75.7 versus 66.5 years), more likely to have ischemic heart disease (25.4% versus 2.7%), ischemic stroke (36.2% versus 6.3%), intraventricular hemorrhage (40.2% versus 27.5%), and larger baseline hematoma volume (mean, 28.1 versus 22.6 mL) than the no‐antiplatelet group. Pre‐ICH antiplatelet therapy was associated with a significantly increased risk of hematoma expansion (adjusted odds ratio [OR], 1.28; 95% CI, 1.01–1.63), a shift toward unfavorable outcome in modified Rankin Scale (adjusted common OR, 1.58; 95% CI, 1.32–1.91) and a higher risk of death at day 90 (adjusted OR, 1.63; 95% CI, 1.25–2.11). Tranexamic acid reduced the risk of hematoma expansion in the overall patients with ICH (adjusted OR, 0.76; 95% CI, 0.62–0.93) and antiplatelet subgroup (adjusted OR, 0.61; 95% CI, 0.41–0.91) with no significant interaction between pre‐ICH antiplatelet therapy and tranexamic acid (P interaction=0.248).

Conclusions

Antiplatelet therapy is independently associated with hematoma expansion and unfavorable functional outcome. Tranexamic acid reduced hematoma expansion regardless of prior antiplatelet therapy use.

Registration

URL: https://www.isrctn.com; Unique identifier: ISRCTN93732214.

Challenging anticoagulation cases: A case of pulmonary embolism shortly after spontaneous brain bleeding

Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.

Treatment of intracerebral hemorrhage: From specific interventions to bundles of care

Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120–130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24–48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.

Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment

Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.

Retrospective Assessment of Desmopressin Effectiveness and Safety in Patients With Antiplatelet-Associated Intracranial Hemorrhage

OBJECTIVE

Current international guidelines offer a conditional recommendation to consider a single dose of IV desmopressin (DDAVP) for antiplatelet-associated intracranial hemorrhage based on low-quality evidence. We provide the first comparative assessment analyzing DDAVP effectiveness and safety in antiplatelet-associated intracranial hemorrhage.

DESIGN

Retrospective chart review.

SETTING

Single tertiary care academic medical center.

PATIENTS

Adult patients taking at least one antiplatelet agent based on presenting history and documented evidence of intracranial hemorrhage on cerebral CT scan were included. Patients were excluded for the following reasons: repeat cerebral CT scan not performed within the first 24 hours, noncomparative repeat cerebral CT scan, chronic anticoagulation, administration of fibrinolytic medications, concurrent ischemic stroke, and neurosurgical intervention. In total, 124 patients were included, 55 received DDAVP and 69 did not.

INTERVENTIONS

DDAVP treatment at recognition of antiplatelet-associated intracranial hemorrhage versus nontreatment.

MEASUREMENTS AND MAIN RESULTS

Primary effectiveness outcome was intracranial hemorrhage expansion greater than or equal to 3 mL during the first 24 hospital hours. Primary safety outcomes were the largest absolute decrease from baseline serum sodium during the first 3 treatment days and new-onset thrombotic events during the first 7 days. DDAVP was associated with 88% decreased likelihood of intracranial hemorrhage expansion during the first 24 hours ([+] DDAVP, 10.9% vs [-] DDAVP, 36.2%; p = 0.002; odds ratio [95% CI], 0.22 [0.08-0.57]). Largest median absolute decrease from baseline serum sodium ([+] DDAVP, 0 mEq/L [0-5 mEq/L] vs [-] DDAVP, 0 mEq/L [0-2 mEq/L]; p = 0.089) and thrombotic events ([+] DDAVP, 7.3% vs [-] DDAVP, 1.4%; p = 0.170; odds ratio [95% CI], 5.33 [0.58-49.16]) were similar between groups.

CONCLUSIONS

DDAVP was associated with a decreased likelihood of intracranial hemorrhage expansion during the first 24 hours. DDAVP administration did not significantly affect serum sodium and thrombotic events during the study period.

Antiplatelet therapy does not increase mortality of surgical treatment for spontaneous intracerebral haemorrhage

OBJECTIVES

This study aimed to find the effect of antiplatelet therapy on hematoma volume, rehaemorrhage rate and prognosis of intracerebral hemorrhage patients after surgery.

PATIENTS AND METHODS

101 surgically treated intracerebral hemorrhage subjects were included and analyzed retrospectively. Prior antiplatelet therapy was ascertained from the clinical history, and the patients included were divided into two groups: antiplatelet therapy and no antiplatelet therapy group. The in-hospital and follow-up outcomes were assessed with the Modified Rankin Scale and were compared between the 2 groups after 1:2 propensity score matching.

RESULTS

Before the diagnosis of intracerebral hemorrhage, 21.8 % patients were not on antiplatelet therapy. Antiplatelet therapy group had larger hematoma volume (99.32 mL versus 73.75 mL) with no significant difference (P = 0.308). After propensity score matching, 42 patients were obtained. 4(9.5 %) had rehaemorrhage after surgery, and antiplatelet therapy was not related to higher rehaemorrhage rate (P = 0.628). After follow-up, the overall mortality was 29.3 %, and 22 patients (53.7 %) ended up with severe morbidity. In the multivariate regression, plasma fibrinogen was an independent predictor of both in-hospital and follow-up overall mortality (P = 0.044; P = 0.016), and prior antiplatelet therapy was found to predict better follow-up functional outcome independently (P = 0.032).

CONCLUSION

Among surgically treated intracerebral hemorrhage patients, prior antiplatelet therapy did not increase hematoma volume, rehaemorrhage rate and mortality, and was related to lower follow-up severe morbidity independently.

Interaction of atrial fibrillation and antithrombotics on outcome in intracerebral hemorrhage

OBJECTIVE

To analyze the clinical differences between patients with primary intracerebral hemorrhage (ICH) with and without atrial fibrillation (AF) and assess whether the effect of the antithrombotic pretreatment on outcome is modified by the presence of AF.

METHODS

In this prospective observational study, researchers from 2 university hospitals included 1,106 consecutive patients with ICH. Clinical characteristics were described and stratified by presence of AF. In-hospital and 3-month mortality and 3-month disability were analyzed, considering antithrombotic pretreatment (none, antiplatelets, or oral anticoagulants) and AF (yes/no).

RESULTS

AF was present in 21.9% of primary ICH cases. Patients with AF-ICH were older, with more vascular risk factors, more antithrombotic pretreatment, higher clinical severity, higher hematoma volume, and higher in-hospital and 3-month mortality. Do-not-resuscitate orders were applied more frequently in AF-ICH cases. After 2 different adjustment models, mortality remained significantly higher in patients with AF-ICH. However, after introducing previous antithrombotic treatment in the model, the adjusted odds ratio for 3-month mortality was 1.45 (95% confidence interval 0.74-2.85, p = 0.284) for patients with AF-ICH compared with non-AF cases. AF modified the effect of antithrombotic pretreatment on in-hospital (p _int = 0.077) and 3-month mortality (p _int = 0.008). Among patients without AF, antithrombotic pretreatment increased mortality; no effect was observed in patients with AF-ICH.

CONCLUSIONS

Patients with AF and ICH had increased mortality; however, AF had no independent effect on mortality after adjustment for antithrombotic pretreatment. Conversely, antithrombotic pretreatment had a deleterious effect on outcome in patients with ICH without AF, but no detectable effect in patients with AF with ICH.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Background

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Methods

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

Results

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

Conclusions

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.

Effects of Prior Antiplatelet Therapy on the Prognosis of Primary Intracerebral Hemorrhage: A Meta-analysis

BACKGROUND

Antiplatelet therapy (APT) was prevalently being used in the prevention of vascular disease, but the influence of prior APT on the prognosis of patients with intracerebral hemorrhage (ICH) remains controversial. This meta-analysis was to explore the effects of prior APT on the prognosis of patients with primary ICH.

METHODS

PubMed and Embase were searched to identify the eligible studies. The studies comparing the mortality of ICH patients with or without prior APT were included. The quality of these studies was evaluated by the Newcastle-Ottawa quality assessment scale. The adjusted or unadjusted odds ratio (OR) for mortality between ICH patients with and without prior APT were pooled with 95% confidence interval (95% CI) as the effect of this meta-analysis.

RESULTS

Twenty-two studies fulfilled the inclusion criteria and exhibited high qualities. The pooled OR was 1.37 (95% CI: 1.13-1.66, P = 0.001) for univariate analysis and 1.41 (95% CI: 1.05-1.90, P = 0.024) for multivariate analysis. The meta-regression indicated that for each 1-day increase in the time of assessment, the adjusted OR for the mortality of APT patients decreased by 0.0049 (95% CI: 0.0006-0.0091, P = 0.026) as compared to non-APT patients.

CONCLUSION

Prior APT was associated with high mortality in patients with ICH that might be attributed primarily to its strong effect on early time.

Spontaneous Intracerebral Hemorrhage

Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.