1
|
Zhou Y, Wang G, Xue C, He G, Zhang Y, He F, He C, Liang X. Effect of heparin for the prevention of venous thromboembolism in patients with spontaneous intracranial cerebral hemorrhage: a meta-analysis. Ther Adv Drug Saf 2024; 15:20420986241253469. [PMID: 38784386 PMCID: PMC11113067 DOI: 10.1177/20420986241253469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
Background Venous thromboembolism (VTE) has a serious impact on the prognosis of patients with spontaneous intracranial hemorrhage (sICH). However, the use of prophylactic heparin remains controversial. Objectives This study investigated the safety and timing of prophylactic heparin for VTE in patients with sICH. Design This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Methods Two authors systematically searched Web of Science, Cochrane Library, Embase, and PubMed to find all published research before June 2023. The incidence of deep venous thrombosis (DVT) and mortality were set as primary endpoints. Results This meta-analysis included seven randomized controlled trials (RCTs) and five observational studies involving a total of 4419 sICH patients in the heparin (n = 2808) and control (n = 1183) groups. Among these patients, 205 received early heparin administration, while 223 received late heparin administration. The results suggested that, compared to the control group, patients in the heparin group had a lower incidence of VTE [odds ratio (OR), 0.47; 95% CI, 0.31-0.71; p < 0.001], DVT (OR, 0.53; 95% CI, 0.33-0.85; p = 0.009), pulmonary embolism (OR, 0.31 95% CI, 0.15-0.65; p = 0.002), and mortality (OR, 0.70; 95% CI, 0.54-0.90; p = 0.006), but there were no statistical differences in hematoma enlargement, extracranial hematoma, and major disability (p > 0.05). There was no statistically significant difference in DVT, mortality, hematoma enlargement, and extracranial hemorrhage between the early heparin group (<24-48 h) and the late heparin group (p > 0.05). Conclusion In patients with sICH, prophylactic use of heparin may be beneficial because it reduces the incidence of VTE and mortality without increasing the risk of additional bleeding. In addition, early prophylactic use of heparin appears to be safe. However, large-scale RCTs are lacking to support this evidence.
Collapse
Affiliation(s)
- Yifu Zhou
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Gang Wang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Chunxiao Xue
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Guojun He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Yan Zhang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Feilong He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Chenjun He
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Xiaosong Liang
- Department of Neurosurgery, Affiliated Hospital of Shaoxing University, No. 999, South Zhongxing Road, Shaoxing, Zhejiang 312000, China
| |
Collapse
|
2
|
Ironside N, Melmed K, Chen CJ, Dabhi N, Omran S, Park S, Agarwal S, Connolly ES, Claassen J, Hod EA, Roh D. ABO blood type and thromboembolic complications after intracerebral hemorrhage: An exploratory analysis. J Stroke Cerebrovasc Dis 2024; 33:107678. [PMID: 38479493 PMCID: PMC11097653 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/03/2024] [Accepted: 03/10/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND AND PURPOSE Non-O blood types are known to be associated with thromboembolic complications (TECs) in population-based studies. TECs are known drivers of morbidity and mortality in intracerebral hemorrhage (ICH) patients, yet the relationships of blood type on TECs in this patient population are unknown. We sought to explore the relationships between ABO blood type and TECs in ICH patients. METHODS Consecutive adult ICH patients enrolled into a prospective observational cohort study with available ABO blood type data were analyzed. Patients with cancer history, prior thromboembolism, and baseline laboratory evidence of coagulopathy were excluded. The primary exposure variable was blood type (non-O versus O). The primary outcome was composite TEC, defined as pulmonary embolism, deep venous thrombosis, ischemic stroke or myocardial infarction, during the hospital stay. Relationships between blood type, TECs and clinical outcomes were separately assessed using logistic regression models after adjusting for sex, ethnicity and ICH score. RESULTS Of 301 ICH patients included for analysis, 44% were non-O blood type. Non-O blood type was associated with higher admission GCS and lower ICH score on baseline comparisons. We identified TECs in 11.6% of our overall patient cohort. . Although TECs were identified in 9.9% of non-O blood type patients compared to 13.0% in O blood type patients, we did not identify a significant relationship of non-O blood type with TECs (adjusted OR=0.776, 95%CI: 0.348-1.733, p=0.537). The prevalence of specific TECs were also comparable in unadjusted and adjusted analyses between the two cohorts. In additional analyses, we identified that TECs were associated with poor 90-day mRS (adjusted OR=3.452, 95% CI: 1.001-11.903, p=0.050). We did not identify relationships between ABO blood type and poor 90-day mRS (adjusted OR=0.994, 95% CI:0.465-2.128, p=0.988). CONCLUSIONS We identified that TECs were associated with worse ICH outcomes. However, we did not identify relationships in ABO blood type and TECs. Further work is required to assess best diagnostic and prophylactic and treatment strategies for TECs to improve ICH outcomes.
Collapse
Affiliation(s)
- Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Kara Melmed
- Department of Neurology and Neurosurgery, New York University Grossman School of Medicine, New York, NY, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Nisha Dabhi
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Setareh Omran
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY 10032, United States
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY 10032, United States
| | - E Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY 10032, United States
| | - Eldad A Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - David Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY 10032, United States.
| |
Collapse
|
3
|
Dong C, Li Y, Ma Md Z. Venous Thromboembolism Prophylaxis After Spontaneous Intracerebral Hemorrhage: A Review. Neurologist 2024; 29:54-58. [PMID: 37582632 DOI: 10.1097/nrl.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Patients with spontaneous intracerebral hemorrhage (sICH) are at high risk for venous thromboembolism (VTE). The administration of mechanical and pharmacological VTE prophylaxis after sICH is important but challenging. The safety and efficacy of the optimal anticoagulant dose, timing, and type of VTE chemoprophylaxis in cases of sICH are still unclear, and clinicians are concerned that it may lead to cerebral hematoma expansion, which is associated with poor prognosis. Through this literature review, we aim to summarize the latest guidelines, recommendations, and clinical research progress to support evidence-based treatment strategies. REVIEW SUMMARY It has been proven that intermittent pneumatic compression can effectively reduce the risk of VTE and should be used at the time of hospital admission, whereas gradient compression stockings or lack of prophylaxis in sICH cases are not recommended by current guidelines. Studies regarding pharmacological VTE prophylaxis in patients with ICH were reviewed and summarized. Prophylactic anticoagulation for VTE in patients with ICH seems to be safe and was not associated with cerebral hematoma expansion. Meanwhile, the prophylactic efficacy of anticoagulation for pulmonary embolism seems to be more obvious than that of deep vein thrombosis in patients with ICH. CONCLUSIONS Clinicians should pay attention to the prevention and management of VTE after sICH. Intermittent pneumatic compression should be applied to patients with sICH on the day of hospital admission. After documentation of bleeding cessation, early initiation of pharmacological VTE prophylaxis (24 h to 48 h from sICH onset) seems to be safe and effective in pulmonary embolism prophylaxis.
Collapse
Affiliation(s)
- Chang Dong
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Dalian Medical University
| | - Ying Li
- Department of Neurology, Dalian Municipal Central Hospital
| | - Zhuang Ma Md
- Department of Clinical Medicine, Graduate School of Dalian Medical University, Dalian Medical University, Dalian
- Department of Respiratory and Critical Care Medicine, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
4
|
Mendel R, Abdelhameed N, Salman RAS, Cohen H, Dowlatshahi D, Freemantle N, Paciaroni M, Parry-Jones A, Price C, Sprigg N, Werring DJ. Prevention of venous thromboembolism in acute spontaneous intracerebral haemorrhage: A survey of opinion. J Neurol Sci 2023; 454:120855. [PMID: 38236754 DOI: 10.1016/j.jns.2023.120855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 01/23/2024]
Abstract
INTRODUCTION People immobilized following acute spontaneous intracerebral haemorrhage (ICH) are at risk of venous thromboembolism (VTE) but the role of short-term prophylactic anticoagulation remains uncertain. We surveyed UK clinical practice and opinion regarding preventing VTE after ICH. PATIENTS AND METHODS An online survey was sent to stroke healthcare professionals within the United Kingdom and Ireland via a professional society (British and Irish Association of Stroke Physicians (BIASP)). RESULTS One hundred and twenty-three staff members responded to the survey, of whom 80% were consultant stroke physicians. All responders except one considered the issue to be important or extremely important, but only 5 (4%) were "extremely certain" and 51 (41%) "fairly certain" regarding the optimal treatment approach. Intermittent pneumatic compression (IPC) devices alone were the most used method (in 60%) followed by IPC devices and switching to low molecular weight heparin (LMWH) (in 30%). We identified high levels of uncertainty regarding the role of anticoagulation, and its optimal timing; uncertainty was greater in lobar compared to deep ICH. Most respondents (93%) consider a randomised controlled trial investigating the role of pharmacological VTE prophylaxis after acute ICH as important and would consider participation. DISCUSSION AND CONCLUSION The optimal method for the prevention of VTE in non-traumatic ICH patients remains an area of clinical uncertainty. Clinical trials assessing short-term anticoagulation in patients after acute ICH would be beneficial in providing evidence to resolve this clinical dilemma.
Collapse
Affiliation(s)
- Rom Mendel
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK; Department of Neurology, Assuta Ashdod Medical Center, Israel
| | - Nadir Abdelhameed
- Stroke department, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa Brain and Mind Institute and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Adrian Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PR, UK
| | - Christopher Price
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK.
| |
Collapse
|
5
|
Sinha S, Ahuja B, Pandit R, Mishra R, Chatterjee R, Choudhuri AH. Thromboprophylaxis practices in neurocritical care-A cross-sectional survey among neurocritical care practitioners. Indian J Anaesth 2023; 67:703-707. [PMID: 37693020 PMCID: PMC10488571 DOI: 10.4103/ija.ija_862_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Aims Thromboprophylaxis practice patterns are quite diverse in neurocritical care patients. The risk of venous thromboembolism remains high in this group due to prolonged immobilised status, extended length of stay and multiple comorbidities. The aim was to comprehend the thromboprophylaxis practices among neurocritical care practitioners in India. Methods The cross-sectional online questionnaire-based survey was undertaken among the neurocritical care practitioners. Two investigators framed two sets of 15 questions in the first stage and reviewed them with experts. In the second stage, a set of 22 questions was prepared by a third investigator and pretested among ten experts. The questions were emailed to the participants with a link to the survey. The responses were analysed using Statistical Package For The Social Sciences software. Results Of the 185 responses, 53% reported that thromboprophylaxis is practised less often in neurocritical care than in general critical care. The usage of pharmacoprophylaxis among neurosurgical cases, traumatic brain injuries and brain strokes varies widely. There was a preference to use pharmacoprophylaxis in patients with Glasgow Coma Scale (GCS) below nine among many (68.2%), and low molecular weight heparin (LMWH) was the preferred choice in such cases. The reluctance to use heparin because of fear of bleed was high (82%). Most (78.9%) believed pharmacoprophylaxis could reduce venous thromboembolic events (VTEs) and mortality. Conclusion Thromboprophylaxis practices among neurocritical care patients remain quite heterogeneous. There is a dilemma in patients with intracranial haemorrhagic lesions regarding pharmacoprophylaxis.
Collapse
Affiliation(s)
- Sharmili Sinha
- Senior Consultant, Critical Care, Apollo Hospital, Bhubaneswar, Odisha, India
| | | | - Rahul Pandit
- Critical Care, Sir HN Reliance Foundation Hospital, Mumbai, Maharashtra, India
| | - Rajesh Mishra
- Intensivist and Internist, Ahmedabad, Gujarat, India
| | | | | |
Collapse
|
6
|
Ironside N, Melmed K, Chen CJ, Omran S, Park S, Agarwal S, Connolly ES, Claassen J, Hod EA, Roh D. ABO Blood Type and Thromboembolic Complications after Intracerebral Hemorrhage: an exploratory analysis. RESEARCH SQUARE 2023:rs.3.rs-3108135. [PMID: 37546936 PMCID: PMC10402260 DOI: 10.21203/rs.3.rs-3108135/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background and Purpose Non-O blood types are known to be associated with thromboembolic complications (TECs) in population-based studies. TECs are known drivers of morbidity and mortality in intracerebral hemorrhage (ICH) patients, yet the relationships of blood type on TECs in this patient population are unknown. We sought to explore the relationships between ABO blood type and TECs in ICH patients. Methods Consecutive adult ICH patients enrolled into a prospective observational cohort study with available ABO blood type data were analyzed. Patients with cancer history, prior thromboembolism, and baseline laboratory evidence of coagulopathy were excluded. The primary exposure variable was blood type (non-O versus O). The primary outcome was composite TEC, defined as pulmonary embolism, deep venous thrombosis, ischemic stroke or myocardial infarction, during the hospital stay. Relationships between blood type, TECs and clinical outcomes were separately assessed using logistic regression models after adjusting for sex, ethnicity and ICH score. Results Of 301 ICH patients included for analysis, 44% were non-O blood type. Non-O blood type was associated with higher admission GCS and lower ICH score on baseline comparisons. We identified TECs in 11.6% of our overall patient cohort. Although TECs were identified in 9.9% of non-O blood type patients compared to 13.0% in O blood type patients, we did not identify a significant relationship of non-O blood type with TECs (adjusted OR = 0.776, 95%CI: 0.348-1.733, p = 0.537). The prevalence of specific TECs were also comparable in unadjusted and adjusted analyses between the two cohorts. In additional analyses, we identified that TECs were associated with poor 90-day mRS (adjusted OR = 3.452, 95% CI: 1.001-11.903, p = 0.050). We did not identify relationships between ABO blood type and poor 90-day mRS (adjusted OR = 0.994, 95% CI:0.465-2.128, p = 0.988). Conclusions We identified that TECs were associated with worse ICH outcomes. However, we did not identify relationships in ABO blood type and TECs. Further work is required to assess best diagnostic and prophylactic and treatment strategies for TECs to improve ICH outcomes.
Collapse
Affiliation(s)
| | - Kara Melmed
- New York University Grossman School of Medicine
| | - Ching-Jen Chen
- University of Texas Health Science Center at Houston School of Dentistry: The University of Texas Health Science Center at Houston School of Dentistry
| | - Setareh Omran
- Oregon Health & Science University Neurological Sciences Institute: Oregon Health & Science University Brain Institute
| | - Soojin Park
- Columbia University Medical Center: Columbia University Irving Medical Center
| | | | | | - Jan Claassen
- Columbia University Medical Center: Columbia University Irving Medical Center
| | - Eldad A Hod
- CUIMC: Columbia University Irving Medical Center
| | - David Roh
- Columbia University Irving Medical Center
| |
Collapse
|
7
|
Burroughs-Ray DC, VanDillen AF, Jackson CD. Clinical guideline highlights for the hospitalist: 2022 American Heart Association/American Stroke Association Guideline for the management of patients with spontaneous intracerebral hemorrhage. J Hosp Med 2023. [PMID: 36725674 DOI: 10.1002/jhm.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 02/03/2023]
Abstract
2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association RELEASE DATE: May 2022 PRIOR VERSION: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association 2015 DEVELOPER: American Heart Association and American Stroke Association FUNDING SOURCE: None TARGET POPULATION: Adult Patients with Spontaneous Intracerebral Hemorrhage.
Collapse
Affiliation(s)
- Desirée C Burroughs-Ray
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Ariana F VanDillen
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Christopher D Jackson
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| |
Collapse
|
8
|
Cochrane A, Chen C, Stephen J, Rønning OM, Anderson CS, Hankey GJ, Al-Shahi Salman R. Antithrombotic treatment after stroke due to intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 1:CD012144. [PMID: 36700520 PMCID: PMC9878977 DOI: 10.1002/14651858.cd012144.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND This is an update of the Cochrane Review last published in 2017. Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of major adverse cardiovascular events (MACE). Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of ischaemic MACE after ICH, but they may increase the risk of bleeding. OBJECTIVES To determine the overall effectiveness and safety of antithrombotic drugs on MACE and its components for people with ICH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (5 October 2021). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2021, Issue 10), MEDLINE Ovid (from 1948 to October 2021) and Embase Ovid (from 1980 to October 2021). The online registries of clinical trials searched were the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (5 October 2021). We screened the reference lists of included randomised controlled trials (RCTs) for additional, potentially relevant RCTs. SELECTION CRITERIA We selected RCTs in which participants with ICH of any age were allocated to a class of antithrombotic treatment as intervention or comparator. DATA COLLECTION AND ANALYSIS In accordance with standard methodological procedures recommended by Cochrane, two review authors assessed each selected RCT for its risk of bias and extracted data independently. The primary outcome was a composite of MACE, and secondary outcomes included death, individual components of the MACE composite, ICH growth, functional status and cognitive status. We estimated effects using the frequency of outcomes that occurred during the entire duration of follow-up and calculated a risk ratio (RR) for each RCT. We grouped RCTs separately for analysis according to 1) the class(es) of antithrombotic treatment used for the intervention and comparator, and 2) the duration of antithrombotic treatment use (short term versus long term). We pooled the intention-to-treat populations of RCTs using a fixed-effect model for meta-analysis, but used a random-effects model if RCTs differed substantially in their design or there was considerable heterogeneity (I2 ≥ 75%) in their results. We applied GRADE to assess the certainty of the evidence. MAIN RESULTS We identified seven new completed RCTs for this update, resulting in the inclusion of a total of nine RCTs based in secondary care, comprising 1491 participants (average age ranged from 61 to 79 years and the proportion of men ranged from 44% to 67%). The proportion of included RCTs at low risk of bias, by category was: random sequence generation (67%), allocation concealment (67%), performance (22%), detection (78%), attrition (89%), and reporting (78%). For starting versus avoiding short-term prophylactic dose anticoagulation after ICH, no RCT reported MACE. The evidence is very uncertain about the effect of starting short-term prophylactic dose anticoagulation on death (RR 1.00, 95% CI 0.59 to 1.70, P = 1.00; 3 RCTs; very low-certainty evidence), venous thromboembolism (RR 0.84, 95% CI 0.51 to 1.37, P = 0.49; 4 RCTs; very low-certainty evidence), ICH (RR 0.24, 95% CI 0.04 to 1.38, P = 0.11; 2 RCTs; very low-certainty evidence), and independent functional status (RR 2.03, 95% CI 0.78 to 5.25, P = 0.15; 1 RCT; very low-certainty evidence) over 90 days. For starting versus avoiding long-term therapeutic dose oral anticoagulation for atrial fibrillation after ICH, starting long-term therapeutic dose oral anticoagulation probably reduces MACE (RR 0.61, 95% CI 0.40 to 0.94, P = 0.02; 3 RCTs; moderate-certainty evidence) and probably reduces all major occlusive vascular events (RR 0.27, 95% CI 0.14 to 0.53, P = 0.0002; 3 RCTs; moderate-certainty evidence), but probably results in little to no difference in death (RR 1.05, 95% CI 0.62 to 1.78, P = 0.86; 3 RCTs; moderate-certainty evidence), probably increases intracranial haemorrhage (RR 2.43, 95% CI 0.88 to 6.73, P = 0.09; 3 RCTs; moderate-certainty evidence), and may result in little to no difference in independent functional status (RR 0.98, 95% CI 0.78 to 1.24, P = 0.87; 2 RCTs; low-certainty evidence) over one to three years. For starting versus avoiding long-term antiplatelet therapy after ICH, the evidence is uncertain about the effects of starting long-term antiplatelet therapy on MACE (RR 0.89, 95% CI 0.64 to 1.22, P = 0.46; 1 RCT; moderate-certainty evidence), death (RR 1.08, 95% CI 0.76 to 1.53, P = 0.66; 1 RCT; moderate-certainty evidence), all major occlusive vascular events (RR 1.03, 95% CI 0.68 to 1.55, P = 0.90; 1 RCT; moderate-certainty evidence), ICH (RR 0.52, 95% CI 0.27 to 1.03, P = 0.06; 1 RCT; moderate-certainty evidence) and independent functional status (RR 0.95, 95% CI 0.77 to 1.18, P = 0.67; 1 RCT; moderate-certainty evidence) over a median follow-up of two years. For adults within 180 days of non-cardioembolic ischaemic stroke or transient ischaemic attack and a clinical history of prior ICH, there was no evidence of an effect of long-term cilostazol compared to aspirin on MACE (RR 1.33, 95% CI 0.74 to 2.40, P = 0.34; subgroup of 1 RCT; low-certainty evidence), death (RR 1.65, 95% CI 0.55 to 4.91, P = 0.37; subgroup of 1 RCT; low-certainty evidence), or ICH (RR 1.29, 95% CI 0.35 to 4.69, P = 0.70; subgroup of 1 RCT; low-certainty evidence) over a median follow-up of 1.8 years; all major occlusive vascular events and functional status were not reported. AUTHORS' CONCLUSIONS We did not identify beneficial or hazardous effects of short-term prophylactic dose parenteral anticoagulation and long-term oral antiplatelet therapy after ICH on important outcomes. Although there was a significant reduction in MACE and all major occlusive vascular events after long-term treatment with therapeutic dose oral anticoagulation for atrial fibrillation after ICH, the pooled estimates were imprecise, the certainty of evidence was only moderate, and effects on other important outcomes were uncertain. Large RCTs with a low risk of bias are required to resolve the ongoing dilemmas about antithrombotic treatment after ICH.
Collapse
Affiliation(s)
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Ole Morten Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | | |
Collapse
|
9
|
Alshaya AI, Alyahya H, Alzoman R, Faden R, Alshaya OA, Al Sulaiman K, Alanazi F, Aldekhyl S. Chemical versus Mechanical and Chemical Venous Thromboembolism Prophylaxis in Neurocritically Ill Patients: A Cohort Study. CLINICAL PHARMACOLOGY : ADVANCES AND APPLICATIONS 2023; 15:1-8. [PMID: 36644519 PMCID: PMC9833649 DOI: 10.2147/cpaa.s388950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/24/2022] [Indexed: 01/09/2023]
Abstract
Purpose Patients admitted with neurocritical illness are presumed to be at high risk for venous thromboembolism (VTE). The administration of chemical and/or mechanical VTE prophylaxis is a common practice in critically ill patients. Recent data did not show a significant difference in the incidence of VTE between chemical compared to a combined chemical and mechanical VTE prophylaxis in critically ill patients with limited data in neurocritically ill population. The objective of this study is to investigate the incidence of VTE between chemical alone compared to chemical and mechanical VTE prophylaxis in neurocritically ill patients. Patients and Methods This was a retrospective cohort study at a tertiary teaching hospital. Data were obtained from electronic medical records for all patients admitted with neurocritical illness from January 1, 2016, to December 31, 2020. Patients were excluded if they did not receive VTE prophylaxis during admission or were younger than 18 YO. Major outcomes were symptomatic VTE based on clinical and radiological findings, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Minor outcomes included severe or life-threatening bleeding based on GUSTO criteria, and mortality at 28-days. Results Two hundred and twelve patients were included in this study. Patients did not have any significant differences in their baseline characteristics. The incidence of VTE was similar in the chemical only group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 7/46 (15.2%)); P = 0.49. No difference between groups in their ICU LOS 6 [3-16.2] vs 6.5 [3-19]; P = 0.52, nor their mortality (18/166 (10.7%) vs 3/46 (6.5%)); P = 0.38, respectively. Less bleeding events were seen in the chemical prophylaxis group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 12/46 (26.1%); P = 0.01). Conclusion Our findings observed no difference between the administration of chemical VTE prophylaxis alone compared to the combined VTE prophylaxis strategy. More data are needed to confirm this finding with more robust methodology.
Collapse
Affiliation(s)
- Abdulrahman I Alshaya
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,Correspondence: Abdulrahman I Alshaya, Clinical Affairs, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Saudi Arabia, Tel +966 11-429-9999, Fax +966 11-849-5085, Email
| | - Hayaa Alyahya
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reema Alzoman
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rawa Faden
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar A Alshaya
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Khalid Al Sulaiman
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Faisal Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Sara Aldekhyl
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
10
|
Wang G, Zhao W, Zhao Z, Wang D, Wang D, Bai R, Hou B, Ren H. Leukocyte as an Independent Predictor of Lower-Extremity Deep Venous Thrombosis in Elderly Patients With Primary Intracerebral Hemorrhage. Front Neurol 2022; 13:899849. [PMID: 35903126 PMCID: PMC9314880 DOI: 10.3389/fneur.2022.899849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Due to the interaction of leukocytes with platelets and coagulation factors, they may in turn play a role in hemostasis or the formation of thrombi. This study aimed to investigate the association of leukocytosis on admission with an increased risk of acute lower-extremity deep venous thrombosis (LEDVT) in elderly patients with primary intracerebral hemorrhage (ICH). Methods This was a single-center, retrospective observational study of consecutive patients observed with spontaneous ICH aged 60 years or above at Lanzhou University Second Hospital from January 2017 to September 2021. Clinical data and demographic information were collected and analyzed. Univariate and multivariate analyses were conducted to identify independent risk factors of acute LEDVT. One-to-one matching was implemented to balance important patient characteristics by the groups' propensity score matching (PSM) analysis. Results A total of 371 elderly patients with primary ICH fulfilled requirements for inclusion and exclusion, of whom 33 (8.89%) experienced LEDVT. Leukocyte counts were statistically higher in the LEDVT group compared to the non-LEDVT group [12.89 (8.80–14.61) × 109 cells/L vs. 8.31 (6.60–10.75) × 109 cells /L, p < 0.001]. Multivariate logistic regression models adjusted for several potential confounding factors were performed, and leukocytes were consistently a significant independent predictor of LEDVT. The optimal cut-off value of leukocyte counts calculated from the receiver operating characteristic (ROC) curve to predict LEDVT was 10.22 × 109 cells /L (area under the curve:0.714, 95%CI 0.665–0.759; the sensitivity was 72.73%; the specificity was 71.01%) in elderly patients with primary ICH. After one-to-one PSM, compared to the matched non-LEDVT group, the matched LEDVT group had significantly higher leukocyte counts [11.98 (8.40–13.94) × 109 cells/L vs. 6.12 (4.68–12.00) × 109 cells/L, p = 0.003]. After PSM, the ROC curve was plotted for leukocytes as a predictor of LEDVT, with an AUC of 0.722 (95%CI 0.593–0.828, p = 0.001; the sensitivity was 87.10%, and the specificity was 61.29%). Elevated leukocytes remained independently significant as predictors of LEDVT in elderly patients with primary ICH. Conclusion Leukocyte at admission is an independent risk factor of LEDVT in elderly patients with primary ICH.
Collapse
Affiliation(s)
- Gang Wang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
| | - Wenjun Zhao
- Department of Health Management Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhiyong Zhao
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
| | - Dengfeng Wang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
| | - Dong Wang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
| | - Ruobing Bai
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
| | - Boru Hou
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
- *Correspondence: Boru Hou
| | - Haijun Ren
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, China
- Key Laboratory of Neurology of Gansu Province, Lanzhou, China
- Haijun Ren
| |
Collapse
|
11
|
Chi G, Lee JJ, Sheng S, Marszalek J, Chuang ML. Systematic Review and Meta-Analysis of Thromboprophylaxis with Heparins Following Intracerebral Hemorrhage. Thromb Haemost 2022; 122:1159-1168. [PMID: 35717948 DOI: 10.1055/s-0042-1744541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The efficacy and safety of pharmacological thromboprophylaxis in patients with intracerebral hemorrhage (ICH) remains unclear. METHODS A literature search was performed to collect studies comparing the effect of thromboprophylaxis in patients with ICH. The primary endpoints were deep vein thrombosis (DVT), pulmonary embolism (PE), and hematoma expansion or rebleeding. A meta-analytic approach was employed to estimate the relative risk (RR) by fitting fixed-effects (FE) and random-effects (RE) models. RESULTS A total of 28 studies representing 3,697 hospitalized patients with ICH were included. Thromboprophylaxis was initiated within 4 days following hospital presentation and continued for 10 to 14 days in most of studies. Compared with control, thromboprophylaxis was associated with a reduced risk of DVT (47/1,399 [3.4%] vs. 202/1,377 [14.7%]; FE: RR, 0.24; 95% CI, 0.18-0.32; RE: RR, 0.27; 95% CI, 0.19-0.39) as well as PE (9/953 [0.9%] vs. 37/864 [4.3%]; FE: RR, 0.33; 95% CI, 0.19-0.57; RE: RR, 0.37; 95% CI, 0.21-0.66). Thromboprophylaxis was not associated with increased risk of hematoma expansion or rebleeding (32/1,319 [2.4%] vs. 37/1,301 [2.8%]; FE: RR, 0.75; 95% CI, 0.48-1.18; RE: RR, 0.80; 95% CI, 0.49-1.30) or mortality (117/925 [12.6%] vs. 139/904 [15.4%]; FE: RR, 0.82; 95% CI, 0.65-1.03; RE: RR, 0.83; 95% CI, 0.66-1.04). CONCLUSION Thromboprophylaxis was effective in preventing DVT and PE without increasing the risk of hematoma expansion or bleeding among ICH patients. Future studies should explore the long-term effects of thromboprophylaxis in this population, particularly on the functional outcomes.
Collapse
Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Jane J Lee
- Department of Trial Design and Development, Baim Institute for Clinical Research, Boston, Massachusetts, United States
| | - Shi Sheng
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jolanta Marszalek
- Department of Neurology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California, United States
| | - Michael L Chuang
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
12
|
Li L, Murthy SB. Cardiovascular Events After Intracerebral Hemorrhage. Stroke 2022; 53:2131-2141. [DOI: 10.1161/strokeaha.122.036884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.
Collapse
Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L.)
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (S.B.M.)
| |
Collapse
|
13
|
Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 305] [Impact Index Per Article: 152.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
| | | | | | | |
Collapse
|
14
|
Surgery for Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
15
|
Shojaei F, Chi G, Memar Montazerin S, Najafi H, Lee JJ, Marszalek J, Kaddouh F, Seifi A. Clinical outcomes of pharmacological thromboprophylaxis among patients with intracerebral hemorrhage: Systematic review and meta-analysis. Clin Neurol Neurosurg 2021; 212:107066. [PMID: 34883283 DOI: 10.1016/j.clineuro.2021.107066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/03/2021] [Accepted: 11/21/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Efficacy and safety of pharmacologic thromboprophylaxis after an episode of intracerebral hemorrhage remains unclear. This meta-analysis aimed at comparing the clinical outcomes of intracerebral hemorrhage patients with or without pharmacologic thromboprophylaxis. METHODS We performed a comprehensive literature review of PubMed to identified relevant studies. The primary and secondary endpoints included venous thromboembolism, deep venous thrombosis, pulmonary emboli, rebleeding, hematoma enlargement (defined as increase in hematoma volume of ≥33%), major disability (defined as modified Rankin score of 3-5), and death. Pooled outcomes were estimated by fitting random effects model with restricted maximum likelihood method. A total of 8 original studies including 3893 patients were analyzed. RESULT Compared to the control group, pharmacologic thromboprophylaxis was associated with a lower risk of pulmonary embolism (odds ratio [OR]: 0.34, 95% CI: 0.15-0.80, P = 0.01). There was no significant difference in the risk of DVT (OR: 0.75; [95% CI: 0.37-1.53], P = 0.44) and VTE (OR: 0.65; [95% CI: 0.34-1.25], P = 0.20). Finally, anticoagulation was not associated with an increase rate of major disability (OR:1.36; [95% CI: 0.57 - 3.23], P = 0.48), rebleeding (OR: 0.35; [95% CI: 0.10-1.19], P = 0.09), hematoma enlargement (OR:1.34; [95% CI: 0.58-3.12], P = 0.49), or death (OR:0.90; [95% CI: 0.68-1.19], P = 0.46). CONCLUSION Among patients with intracerebral hemorrhage, pharmacologic thromboprophylaxis was associated with a significant reduction in pulmonary embolism, without an increase in rebleeding or hematoma enlargement. The results of this meta-analysis need to be further validated in large scale clinical trials.
Collapse
Affiliation(s)
- Fahimehalsadat Shojaei
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Sahar Memar Montazerin
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Homa Najafi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Jane J Lee
- Baim Institute for Clinical Research, Boston, MA 02215, USA.
| | - Jolanta Marszalek
- Department of Neurology, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, USA.
| | - Firas Kaddouh
- Division of Neuro Critical Care, Department of Neurosurgery, UT Health, San Antonio, TX, USA.
| | - Ali Seifi
- Division of Neuro Critical Care, Department of Neurosurgery, UT Health, San Antonio, TX, USA.
| |
Collapse
|
16
|
Laurent D, Bardhi O, Kubilis P, Corliss B, Adamczak S, Geh N, Dodd W, Vaziri S, Busl K, Fox WC. Early chemoprophylaxis for deep venous thrombosis does not increase the risk of hematoma expansion in patients presenting with spontaneous intracerebral hemorrhage. Surg Neurol Int 2021; 12:277. [PMID: 34221608 PMCID: PMC8247662 DOI: 10.25259/sni_100_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Spontaneous intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality worldwide. The development of venous thromboembolism (VTE), including deep venous thrombosis or pulmonary embolism, is correlated with negative outcomes following ICH. Due to the risk of hematoma expansion associated with the use of VTE chemoprophylaxis, there remains significant debate about the optimal timing for its initiation following ICH. We analyzed the risk of early chemoprophylaxis on hematoma expansion following ICH. Methods: We performed a retrospective analysis of patients presenting with spontaneous ICH at single institution between 2011 and 2018. The rate of hematoma expansion was compared between patients that received early chemoprophylaxis (on admission) and those that received conventional chemoprophylaxis (>24 h). Results: Data for 235 patients were available for analysis. Eleven patients (7.5%) in the early prophylaxis cohort and seven patients (8.0%) in the conventional prophylaxis cohort developed VTE (P = 0.9). Hematoma expansion also did not differ significantly (early 19%, conventional 23%, P = 0.5). Conclusion: The use of early chemoprophylaxis against venous thromboembolic events following ICH appears safe in our patient population without increasing the risk of hematoma expansion. Given the increased risk of poor outcome in the setting of VTE, early VTE chemoprophylaxis should be considered in patients who present with ICH. Larger, prospective, and randomized studies are necessary to better elucidate the risk of early chemoprophylaxis and potential reduction in venous thromboembolic events.
Collapse
Affiliation(s)
- Dimitri Laurent
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Olgert Bardhi
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Paul Kubilis
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Brian Corliss
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Stephanie Adamczak
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Ndi Geh
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - William Dodd
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Sasha Vaziri
- Department of Neurosurgery, Lillian S. Wells, University of Florida, Florida, United States
| | - Katharina Busl
- Department of Neurology, University of Florida, Gainesville, Florida, United States
| | - W Christopher Fox
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
| |
Collapse
|
17
|
Song JC, Yang LK, Zhao W, Zhu F, Wang G, Chen YP, Li WQ. Chinese expert consensus on diagnosis and treatment of trauma-induced hypercoagulopathy. Mil Med Res 2021; 8:25. [PMID: 33840386 PMCID: PMC8040221 DOI: 10.1186/s40779-021-00317-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022] Open
Abstract
Trauma-induced coagulopathy (TIC) is caused by post-traumatic tissue injury and manifests as hypercoagulability that leads to thromboembolism or hypocoagulability that leads to uncontrollable massive hemorrhage. Previous studies on TIC have mainly focused on hemorrhagic coagulopathy caused by the hypocoagulable phenotype of TIC, while recent studies have found that trauma-induced hypercoagulopathy can occur in as many as 22.2-85.1% of trauma patients, in whom it can increase the risk of thrombotic events and mortality by 2- to 4-fold. Therefore, the Chinese People's Liberation Army Professional Committee of Critical Care Medicine and the Chinese Society of Thrombosis, Hemostasis and Critical Care, Chinese Medicine Education Association jointly formulated this Chinese Expert Consensus comprising 15 recommendations for the definition, pathophysiological mechanism, assessment, prevention, and treatment of trauma-induced hypercoagulopathy.
Collapse
Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 330002, China.
| | - Li-Kun Yang
- Department of Neurosurgery, the 904th Hospital of Joint Logistics Support Forces of Chinese PLA, Wuxi, 214044, Jiangsu, China
| | - Wei Zhao
- Division of Vascular and Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University, Shanghai, 200120, China
| | - Gang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710001, China
| | - Yao-Peng Chen
- Department of Blood Transfusion, the 923th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanning, 530021, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, General Hospital of Eastern Theater Command of Chinese PLA, Nanjing, 210002, China.
| | | |
Collapse
|
18
|
Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 384] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
Collapse
Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
| |
Collapse
|
19
|
Becattini C, Cimini LA, Carrier M. Challenging anticoagulation cases: A case of pulmonary embolism shortly after spontaneous brain bleeding. Thromb Res 2021; 200:41-47. [PMID: 33529872 DOI: 10.1016/j.thromres.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
Abstract
Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.
Collapse
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| |
Collapse
|
20
|
Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
Collapse
Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
| |
Collapse
|
21
|
Elmi G, Aluigi L, Allegri D, Rinaldi ER, Camaggi V, Di Giulio R, Martignani A, Bacchi Reggiani ML, Domanico A, Antignani PL. Calf deep vein thrombosis: frequency, therapeutic management, early outcomes and all-causes mortality in a cohort of hospitalized patients. INT ANGIOL 2020; 39:467-476. [PMID: 33215909 DOI: 10.23736/s0392-9590.20.04528-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Isolated distal deep vein thromboses (IDDVT) are frequent; however, their optimal management is still controversial. METHODS We performed a retrospective study on inpatients undergoing ultrasound for suspected deep vein thrombosis (DVT) or with a particular risk profile, during 2016. This study aimed to assess the frequency of proximal deep vein thromboses (PDVT) and IDDVT; to evaluate therapeutic management and identify variables associated with early outcomes and mortality among IDDVT patients; to compare all-causes mortality between subjects with PDVT and IDDVT. RESULTS Among 21594 patients hospitalized in the study period 251 IDDVT and 149 PDVT were diagnosed; the frequency was 1.2% and 0.7% respectively. 19% of IDDVT patients died compared to 25.5% of PDVT subjects (OR=0.72; 95% CI=0.44-1.17; P=0.19). In IDDVT patients, age ≥80, cancer and intracranial bleeding increased the risk of death (OR=2; 95% CI=1.07-3.75, P=0.001; OR=8.47; 95% CI=3.28-21.88, P=0.0000003; OR=2.33; 95% CI=1.18-4.58, P=0.0003). A significant association between intracranial hemorrhage and both proximal extension by using the Fisher's exact test (P=0.031; OR=16.11; 95% CI=0.80-321.2), and composite of propagation to popliteal or to other calf veins (OR=8.28, 95% CI=2.07-33 P=0.001) was observed. Standard anticoagulation significantly reduced the composite of propagation to popliteal or to other calf veins (OR=0.07; 95% CI=0.009-0.61, P=0.007), and all-causes mortality (OR=0.37; 95% CI=0.17-0.8; P=0.02), without a significant increase of bleeding. CONCLUSIONS Among inpatients, IDDVT exceeded 60% of DVT. Mortality was not significantly different between IDDVT and PDVT subjects. Intracranial bleeding significantly increased the risk of propagation and death. Although standard anticoagulation decreased both these complications, further targeted studies are needed.
Collapse
Affiliation(s)
- Giovanna Elmi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy -
| | | | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Elisa R Rinaldi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Valeria Camaggi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Rosella Di Giulio
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Alberto Martignani
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Maria L Bacchi Reggiani
- Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Domanico
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | | |
Collapse
|
22
|
Kananeh MF, Fonseca-Paricio MJ, Liang JW, Sullivan LT, Sharma K, Shah SO, Vibbert MD. Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH). J Stroke Cerebrovasc Dis 2020; 30:105476. [PMID: 33253987 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). BACKGROUND Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. METHODS We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality. RESULTS A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. CONCLUSION Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.
Collapse
Affiliation(s)
- Mohammed F Kananeh
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | | | - John W Liang
- Mount Sinai Heath System, Department of Neurosurgery & Neurology, New York, New York, USA
| | - Lindsay T Sullivan
- Novant Health Forsyth Medical Center, Department of Neurology, Winston-Salem, North Carolina, USA
| | - Kumud Sharma
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | - Syed Omar Shah
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA.
| | - Matthew D Vibbert
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
Collapse
Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
| |
Collapse
|
24
|
Yogendrakumar V, Lun R, Khan F, Salottolo K, Lacut K, Graham C, Dennis M, Hutton B, Wells PS, Fergusson D, Dowlatshahi D. Venous thromboembolism prevention in intracerebral hemorrhage: A systematic review and network meta-analysis. PLoS One 2020; 15:e0234957. [PMID: 32579570 PMCID: PMC7314010 DOI: 10.1371/journal.pone.0234957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/02/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION To summarize and compare the effectiveness of pharmacological thromboprophylaxis to pneumatic compression devices (PCD) for the prevention of venous thromboembolism in patients with acute intracerebral hemorrhage. METHODS MEDLINE, PUBMED, EMBASE, and CENTRAL were systematically searched to identify randomized and non-randomized studies that compared each intervention directly to each other or against a common control (hydration, anti-platelet agents, stockings) in adults with acute spontaneous intracerebral hemorrhage. Two investigators independently screened the studies, extracted data, and appraised risk of bias. Studies with a high risk of bias were excluded from our final analysis. The primary outcome was the occurrence of venous thromboembolism (proximal deep vein thrombosis or pulmonary embolism) in the first 30 days. RESULTS 8,739 articles were screened; four articles, all randomized control trials, met eligibility criteria. Bayesian network meta-analysis was performed to calculate risk estimates using both fixed and random effects analyses. 607 patients were included in the network analysis. PCD were associated with a significant decrease in venous thromboembolism compared to control (OR: 0.43, 95% Credible Limits [CrI]: 0.23-0.80). We did not find evidence of statistically significant differences between pharmacological thromboprophylaxis and control (OR: 0.93, 95% CrI: 0.19-4.37) or between PCD and pharmacological thromboprophylaxis (OR: 0.47, 95% CrI: 0.09-2.54). CONCLUSION PCDs are superior to control interventions, but meaningful comparisons with pharmacotherapy are not possible due to a lack of data. This requires further exploration via large pragmatic clinical trials. TRIAL REGISTRATION PROSPERO: CRD42018090960.
Collapse
Affiliation(s)
- Vignan Yogendrakumar
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ronda Lun
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Faizan Khan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kristin Salottolo
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado, United States of America
| | - Karine Lacut
- EA3878, Université de Bretagne Occidentale, Brest, France
| | - Catriona Graham
- Wellcome Trust Clinical Research Facility, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Philip S. Wells
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
25
|
Melmed KR, Boehme A, Ironside N, Murthy S, Park S, Agarwal S, Connolly ES, Claassen J, Elkind MSV, Roh D. Respiratory and Blood Stream Infections are Associated with Subsequent Venous Thromboembolism After Primary Intracerebral Hemorrhage. Neurocrit Care 2020; 34:85-91. [PMID: 32385835 PMCID: PMC7223996 DOI: 10.1007/s12028-020-00974-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infection and venous thromboembolism (VTE) are associated with worse outcomes after intracerebral hemorrhage (ICH). The relationship between infection and VTE in ICH patients is unclear. We hypothesized that infection would be associated with subsequent VTE after ICH. METHODS We retrospectively studied consecutively admitted spontaneous primary ICH patients from 2009 to 2018 surviving beyond 24 h. The primary predictor variable was infection, diagnosed prior to VTE. The primary outcome was VTE. We used multivariable logistic regression models to estimate the odds ratios and 95% confidence intervals (OR, 95% CI) for VTE risk after infection of any type, after adjusting for ICH score, length of stay and days to deep venous thrombosis (DVT) prophylaxis. Similar analysis was done to estimate the association of infection subtypes, including respiratory and urinary and blood stream infections (BSI) with VTE. RESULTS There were 414 patients (mean age 65 years, 47% female) that met were analyzed. Infection was diagnosed in 181 (44%) patients. Incident VTE was diagnosed in 36 (9%) patients, largely comprised of DVT (n = 32; 89%). Infection overall was associated with increased risk of subsequent VTE (adjusted OR 4.5, 95% CI 1.6-12.6). Respiratory (adjusted OR 5.7, 95% CI 2.8-11.7) and BSI (adjusted OR 4.0, 95% CI 1.3-11.0) were associated with future VTE. Urinary and other infections were not associated with subsequent VTE. CONCLUSIONS Infections are associated with subsequent risk of VTE among patients with ICH. Further investigation is required to elucidate mechanisms behind this association and to improve VTE prevention after ICH.
Collapse
Affiliation(s)
- Kara R Melmed
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
- Department of Neurology, NYU Langone Health, New York, NY, USA.
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Natasha Ironside
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
26
|
Zhang P, Bian Y, Xu F, Lian L, Zhu S, Tang Z, Wang F. The Incidence and Characteristics of Venous Thromboembolism in Neurocritical Care Patients: A Prospective Observational Study. Clin Appl Thromb Hemost 2020; 26:1076029620907954. [PMID: 32090609 PMCID: PMC7288821 DOI: 10.1177/1076029620907954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is presumed to be high for neurologic intensive care unit (NICU) patients. However, exact incidences of VTE have yet to be reported. In this prospective observational study, we consecutively enrolled 126 neurocritical care patients who had an NICU stay ≥1 week with paralysis and/or unconsciousness. All patients received DVT prevention strategies. Patients were screened for VTE after 1 week of hospitalization, using venous ultrasonography and computed tomography pulmonary angiography. Following 1 week of NICU hospitalization, DVT incidence was 35.7% and PE incidence was 17.5%. Of the DVTs, 75.6% were in the muscular calf vein. Of the PEs, 22.7% were in main pulmonary arteries, while 77.3% were in branches. Approximately 96% of the DVTs and 86% of the PEs were asymptomatic. Approximately 24% of patients with DVT had a concurrent PE, while 50% of PE patients had a DVT. Paralysis, raised d-dimer on admission, and pulmonary infection were found to be independent risk factors for DVT. Paraplegia, femoral vein thrombosis, and pulmonary infection were found to be independent risk factors for PE. Despite active preventive measures, incidences of VTE in NICU patients were high. Most VTEs were asymptomatic, meaning they could have led to a missed diagnosis. Attention should be paid to the VTE events of critically ill neurological patients.
Collapse
Affiliation(s)
- Ping Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Bian
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lifei Lian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Furong Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
27
|
STANESCU IC, BULBOACA A, FODOR DM, OBER CD, GUSETU G, DOGARU G. Role of rehabilitation in prevention of early thromboembolic complications in hemorrhagic stroke. BALNEO RESEARCH JOURNAL 2019. [DOI: 10.12680/balneo.2019.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hemorrhagic strokes (ICH) affects mainly young active people, with increasing incidence in developing countries. Mortality is high in acute phase, and patients are prone to complications related to stroke itself and to coexisting medical conditions. Patients with ICH are at high risk in developing deep venous thrombosis (DVT) with secondary pulmonary embolism (PE). Prevention of venous thrombotic events in hemorrhagic stroke patients requires intermittent pneumatic compression and preventive doses of low molecular weight heparins (LMWH) in high-risk patients. If DVT and /or PE occurs, the therapeutic management should balance the risk of recurrent cerebral bleeding and the life-threatening risk of PE, making the decision to start anticoagulation challenging. We present a case of a young patient with a large hypertensive capsulo-lenticular hemorrhage, who was diagnosed with pulmonary embolism 21 days after stroke onset. The decision was for anticoagulant treatment initial with LWMH, and switch to direct oral anticoagulants (DOAC) after 10 days; strict control of vascular risk factors of the patients (hypertension, diabetes and obesity) was achieved. Rehabilitation treatment, delayed until day 21, was recommended with progressive intensity. Evolution of the patient was favorable, with complete hematoma resorbtion under DOAC treatment at 10 weeks follow-up and important motor recovery. Rehabilitation program was intensive during this interval, and strongly contributive to neurologic improvement.
Collapse
Affiliation(s)
- Ioana C. STANESCU
- "Iuliu Hatieganu"University of Medicine and Pharmacy Cluj Napoca, Romania 2. Clinical Rehabilitation Hospital Cluj Napoca, Romania
| | - Angelo BULBOACA
- "Iuliu Hatieganu"University of Medicine and Pharmacy Cluj Napoca, Romania 2. Clinical Rehabilitation Hospital Cluj Napoca, Romania
| | - Dana Marieta FODOR
- "Iuliu Hatieganu"University of Medicine and Pharmacy Cluj Napoca, Romania
| | | | - Gabriel GUSETU
- "Iuliu Hatieganu"University of Medicine and Pharmacy Cluj Napoca, Romania 2. Clinical Rehabilitation Hospital Cluj Napoca, Romania
| | - Gabriela DOGARU
- "Iuliu Hatieganu"University of Medicine and Pharmacy Cluj Napoca, Romania 2. Clinical Rehabilitation Hospital Cluj Napoca, Romania
| |
Collapse
|
28
|
Sprügel MI, Sembill JA, Kuramatsu JB, Gerner ST, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Muellges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Classen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Guenther A, Hamann GF, Lücking H, Dörfler A, Schwab S, Huttner HB. Heparin for prophylaxis of venous thromboembolism in intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2019; 90:783-791. [PMID: 30992334 DOI: 10.1136/jnnp-2018-319786] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the occurrence of intracranial haemorrhagic complications (IHC) on heparin prophylaxis (low-dose subcutaneous heparin, LDSH) in primary spontaneous intracerebral haemorrhage (ICH) (not oral anticoagulation-associated ICH, non-OAC-ICH), vitamin K antagonist (VKA)-associated ICH and non-vitamin K antagonist oral anticoagulant (NOAC)-associated ICH. METHODS Retrospective cohort study (RETRACE) of 22 participating centres and prospective single-centre study with 1702 patients with VKA-associated or NOAC-associated ICH and 1022 patients with non-OAC-ICH with heparin prophylaxis between 2006 and 2015. Outcomes were defined as rates of IHC during hospital stay among patients with non-OAC-ICH, VKA-ICH and NOAC-ICH, mortality and functional outcome at 3 months between patients with ICH with and without IHC. RESULTS IHC occurred in 1.7% (42/2416) of patients with ICH. There were no differences in crude incidence rates among patients with VKA-ICH, NOAC-ICH and non-OAC-ICH (log-rank p=0.645; VKA-ICH: 27/1406 (1.9%), NOAC-ICH 1/130 (0.8%), non-OAC-ICH 14/880 (1.6%); p=0.577). Detailed analysis according to treatment exposure (days with and without LDSH) revealed no differences in incidence rates of IHC per 1000 patient-days (LDSH: 1.43 (1.04-1.93) vs non-LDSH: 1.32 (0.33-3.58), conditional maximum likelihood incidence rate ratio: 1.09 (0.38-4.43); p=0.953). Secondary outcomes showed differences in functional outcome (modified Rankin Scale=4-6: IHC: 29/37 (78.4%) vs non-IHC: 1213/2048 (59.2%); p=0.019) and mortality (IHC: 14/37 (37.8%) vs non-IHC: 485/2048 (23.7%); p=0.045) in disfavour of patients with IHC. Small ICH volume (OR: volume <4.4 mL: 0.18 (0.04-0.78); p=0.022) and low National Institutes of Health Stroke Scale (NIHSS) score on admission (OR: NIHSS <4: 0.29 (0.11-0.78); p=0.014) were significantly associated with fewer IHC. CONCLUSIONS Heparin administration for venous thromboembolism (VTE) prophylaxis in patients with ICH appears to be safe regarding IHC among non-OAC-ICH, VKA-ICH and NOAC-ICH in this observational cohort analysis. Randomised controlled trials are needed to verify the safety and efficacy of heparin compared with other methods for VTE prevention.
Collapse
Affiliation(s)
| | | | | | - Stefan T Gerner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Hagen
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Matthias Endres
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jan Sobesky
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sarah Zweynert
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Neurosurgery, Charité-Universitäts medizin Berlin, Berlin, Germany
| | | | | | - Timolaos Rizos
- Neurology, University of Heidelberg, Heidelberg, Germany
| | - Jens Volkmann
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Peter Kraft
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Frank Erbguth
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Martin Nueckel
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Peter D Schellinger
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Jörg Glahn
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Ulrich J Knappe
- Neurosurgery, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | | | | | | | | | | | - Georg Hagemann
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | - Florian Rakers
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | | | | | | | | | | | | | - Joachim Röther
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | - Peter Michels
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | | | - Gernot Reimann
- Neurology, Community Hospital Dortmund, Dortmund, Germany
| | | | | | | | | | - Armin Grau
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | - Frederick Palm
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | | | | | | | - Markus Horn
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Dirk Bahner
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | | | | | | | - Hannes Lücking
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B Huttner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
29
|
Abstract
IMPORTANCE Although spontaneous intraparenchymal hemorrhage (IPH) accounts for less than 20% of cases of stroke, it continues to be associated with the highest mortality of all forms of stroke and substantial morbidity rates. OBSERVATIONS Early identification and management of IPH is crucial. Blood pressure control, reversal of associated coagulopathy, care in a dedicated stroke unit, and identification of secondary etiologies are essential to optimizing outcomes. Surgical management of hydrocephalus and space occupying hemorrhage in the posterior fossa are accepted forms of treatment. Modern advances in minimally invasive surgical management of primary, supratentorial IPH are being explored in randomized trials. Hemorrhagic arteriovenous malformations and cavernous malformations are surgically excised if accessible, while hemorrhagic dural arteriovenous fistulas and distal/mycotic aneurysms are often managed with embolization if feasible. CONCLUSIONS AND RELEVANCE IPH remains a considerable source of neurological morbidity and mortality. Rapid identification, medical management, and neurosurgical management, when indicated, are essential to facilitate recovery. There is ongoing evaluation of minimally invasive approaches for evacuation of primary IPH and evolution of surgical and endovascular techniques in the management of lesions leading to secondary IPH.
Collapse
Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
30
|
Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
Collapse
Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
| |
Collapse
|
31
|
Ianosi B, Gaasch M, Rass V, Huber L, Hackl W, Kofler M, Schiefecker AJ, Addis A, Beer R, Rhomberg P, Pfausler B, Thomé C, Ammenwerth E, Helbok R. Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage. Eur J Neurol 2018; 26:333-341. [DOI: 10.1111/ene.13830] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/08/2018] [Indexed: 11/28/2022]
Affiliation(s)
- B. Ianosi
- Institute of Medical Informatics; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - M. Gaasch
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - V. Rass
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - L. Huber
- Institute of Medical Informatics; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall
| | - W. Hackl
- Institute of Medical Informatics; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall
| | - M. Kofler
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - A. J. Schiefecker
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - A. Addis
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
- Department of Clinical and Experimental Medicine; University of Sassari; Sassari Italy
| | - R. Beer
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - P. Rhomberg
- Department of Neuroradiology; Medical University of Innsbruck; Innsbruck
| | - B. Pfausler
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - C. Thomé
- Department of Neurosurgery; Medical University of Innsbruck; Innsbruck Austria
| | - E. Ammenwerth
- Institute of Medical Informatics; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall
| | - R. Helbok
- Neurological Intensive Care Unit; Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| |
Collapse
|
32
|
Schünemann HJ, Cushman M, Burnett AE, Kahn SR, Beyer-Westendorf J, Spencer FA, Rezende SM, Zakai NA, Bauer KA, Dentali F, Lansing J, Balduzzi S, Darzi A, Morgano GP, Neumann I, Nieuwlaat R, Yepes-Nuñez JJ, Zhang Y, Wiercioch W. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018; 2:3198-3225. [PMID: 30482763 PMCID: PMC6258910 DOI: 10.1182/bloodadvances.2018022954] [Citation(s) in RCA: 465] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is the third most common vascular disease. Medical inpatients, long-term care residents, persons with minor injuries, and long-distance travelers are at increased risk. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about preventing VTE in these groups. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 19 recommendations for acutely ill and critically ill medical inpatients, people in long-term care facilities, outpatients with minor injuries, and long-distance travelers. CONCLUSIONS Strong recommendations included provision of pharmacological VTE prophylaxis in acutely or critically ill inpatients at acceptable bleeding risk, use of mechanical prophylaxis when bleeding risk is unacceptable, against the use of direct oral anticoagulants during hospitalization, and against extending pharmacological prophylaxis after hospital discharge. Conditional recommendations included not to use VTE prophylaxis routinely in long-term care patients or outpatients with minor VTE risk factors. The panel conditionally recommended use of graduated compression stockings or low-molecular-weight heparin in long-distance travelers only if they are at high risk for VTE.
Collapse
Affiliation(s)
- Holger J Schünemann
- Department of Medicine and
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Allison E Burnett
- Inpatient Antithrombosis Service, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus," Dresden, Germany
- Kings Thrombosis Service, Department of Hematology, Kings College London, United Kingdom
| | | | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Neil A Zakai
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Kenneth A Bauer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | | | - Sara Balduzzi
- Cochrane Italy, Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy; and
| | - Andrea Darzi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Juan J Yepes-Nuñez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
33
|
Ding D, Sekar P, Moomaw CJ, Comeau ME, James ML, Testai F, Flaherty ML, Vashkevich A, Worrall BB, Woo D, Osborne J. Venous Thromboembolism in Patients With Spontaneous Intracerebral Hemorrhage: A Multicenter Study. Neurosurgery 2018; 84:E304-E310. [DOI: 10.1093/neuros/nyy333] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/19/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mary E Comeau
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, North Carolina
| | - Fernando Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Bradford B Worrall
- Department of Neurology, University of Virginia, Charlottesville, Virginia
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Osborne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
34
|
Khan AA, Lip GYH. Resumption of antiplatelet therapy in patients with primary intracranial haemorrhage: Balancing benefits and risks. J Neurol Sci 2018; 384:139-140. [PMID: 29221666 DOI: 10.1016/j.jns.2017.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Ahsan A Khan
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
35
|
Khan MT, Ikram A, Saeed O, Afridi T, Sila CA, Smith MS, Irshad K, Shuaib A. Deep Vein Thrombosis in Acute Stroke - A Systemic Review of the Literature. Cureus 2017; 9:e1982. [PMID: 29503776 PMCID: PMC5825043 DOI: 10.7759/cureus.1982] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/23/2017] [Indexed: 12/22/2022] Open
Abstract
We present a systemic review of available literature on the complications of deep venous thrombosis that develops in patients presenting with acute stroke. There are several pharmacological and physical treatment options available and used. We aim to summarize the management plans currently used at different centers. In conclusion, low-dose anticoagulant therapy for ischemic stroke is recommended. In the case of intracerebral hemorrhage, pneumatic sequential compression devices should be placed initially, followed by the administration of ultra-fractioned heparin on the next day, and then oral anticoagulant therapy to replace the heparin after a week in high-risk patients. Similar prophylactic treatment recommendations are used for subarachnoid hemorrhage.
Collapse
Affiliation(s)
| | - Asad Ikram
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Omar Saeed
- Department of Neurology, Zeenat Qureshi Stroke Insitute
| | | | - Cathy A Sila
- Department of Neurology, University Hospitals Case Western Reserve University School of Medicine
| | | | | | | |
Collapse
|
36
|
Perry LA, Berge E, Bowditch J, Forfang E, Rønning OM, Hankey GJ, Villanueva E, Al‐Shahi Salman R. Antithrombotic treatment after stroke due to intracerebral haemorrhage. Cochrane Database Syst Rev 2017; 5:CD012144. [PMID: 28540976 PMCID: PMC6481874 DOI: 10.1002/14651858.cd012144.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of thromboembolism. Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of thromboembolism after ICH, but they may increase the risks of bleeding. OBJECTIVES To determine the overall effectiveness and safety of antithrombotic drugs for people with ICH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (24 March 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2017, Issue 3), MEDLINE Ovid (from 1948 to March 2017), Embase Ovid (from 1980 to March 2017), and online registries of clinical trials (8 March 2017). We also screened the reference lists of included trials for additional, potentially relevant studies. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) of any antithrombotic treatment after ICH. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. We converted categorical estimates of effect to the risk ratio (RR) or odds ratio (OR), as appropriate. We divided our analyses into short- and long-term treatment, and used fixed-effect modelling for meta-analyses. Three review authors independently assessed the included RCTs for risks of bias and we created a 'Summary of findings' table using GRADE. MAIN RESULTS We included two RCTs with a total of 121 participants. Both RCTs were of short-term parenteral anticoagulation early after ICH: one tested heparin and the other enoxaparin. The risk of bias in the included RCTs was generally unclear or low, with the exception of blinding of participants and personnel, which was not done. The included RCTs did not report our chosen primary outcome (a composite outcome of all serious vascular events including ischaemic stroke, myocardial infarction, other major ischaemic event, ICH, major extracerebral haemorrhage, and vascular death). Parenteral anticoagulation did not cause a statistically significant difference in case fatality (RR 1.25, 95% confidence interval (CI) 0.38 to 4.07 in one RCT involving 46 participants, low-quality evidence), ICH, or major extracerebral haemorrhage (no detected events in one RCT involving 75 participants, low-quality evidence), growth of ICH (RR 1.64, 95% CI 0.51 to 5.29 in two RCTs involving 121 participants, low-quality evidence), deep vein thrombosis (RR 0.99, 95% CI 0.49 to 1.96 in two RCTs involving 121 participants, low quality evidence), or major ischaemic events (RR 0.54, 95% CI 0.23 to 1.28 in two RCTs involving 121 participants, low quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence from RCTs to support or discourage the use of antithrombotic treatment after ICH. RCTs comparing starting versus avoiding antiplatelet or anticoagulant drugs after ICH appear justified and are needed in clinical practice.
Collapse
Affiliation(s)
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | | | - Elisabeth Forfang
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Ole Morten Rønning
- Akershus University HospitalDepartment of NeurologySykehusveien 25LørenskogNorwayNO‐1478
| | - Graeme J Hankey
- The University of Western AustraliaSchool of Medicine, Sir Charles Gairdner Hospital Unit6 Verdun StreetNedlandsPerthWestern AustraliaAustralia6009
| | - Elmer Villanueva
- Xi'an Jiaotong‐Liverpool UniversityDepartment of Public Health111 Ren'ai Road, Dushu Lake Higher Education TownSuzhou Industrial ParkSuzhouJiangsuChina
| | - Rustam Al‐Shahi Salman
- University of EdinburghCentre for Clinical Brain SciencesFU303i, First floor, Chancellor's Building49 Little France CrescentEdinburghMidlothianUKEH16 4SB
| | | |
Collapse
|
37
|
Current Practice Trends for Use of Early Venous Thromboembolism Prophylaxis After Intracerebral Hemorrhage. Neurosurgery 2017; 82:85-92. [DOI: 10.1093/neuros/nyx146] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 03/03/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Venous thromboembolism (VTE) is common after intracerebral hemorrhage (ICH). Guidelines recommend early VTE prophylaxis.
OBJECTIVE
To determine characteristics associated with early chemoprophylaxis (CP) after ICH in the Get With The Guidelines-Stroke registry.
METHODS
In this observational cohort study, we identified patients with ICH between January 1, 2009 and September 30, 2013, who (1) were non-ambulatory and/or not comfort care measures by hospital day 2; (2) were not transferred to another acute care facility; and (3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were as follows: (1) mechanical non-CP or (2) CP with or without mechanical prophylaxis. Early prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors independently associated with early CP use.
RESULTS
Among 74 283 patients with ICH from 1358 hospitals, 5929 (7.9%) received early CP, 66 444 (89.4%) received early mechanical/non-CP, and 1910 (2.6%) had no prophylaxis, mechanical or CP, within the first 2 days. There was no increase in early CP use over the study period; 60% of hospitals provided early CP to <9% of patients. In multivariable analysis, female sex, atrial fibrillation, diabetes, coronary, carotid, and peripheral artery disease, prior ischemic stroke or transient ischemic attack, hospital size >500 beds, and geographic region were independently associated with early vs no early CP use.
CONCLUSION
Nationwide, the large majority of ICH patients receive early mechanical VTE prophylaxis only, without CP. Patient comorbidities and hospital characteristics such as geographic location are determinants of higher use of early CP.
Collapse
|
38
|
Kim JY, Bae HJ. Spontaneous Intracerebral Hemorrhage: Management. J Stroke 2017; 19:28-39. [PMID: 28178413 PMCID: PMC5307946 DOI: 10.5853/jos.2016.01935] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 01/07/2023] Open
Abstract
Spontaneous non-traumatic intracerebral hemorrhage (ICH) remains a significant cause of mortality and morbidity throughout the world. To improve the devastating course of ICH, various clinical trials for medical and surgical interventions have been conducted in the last 10 years. Recent large-scale clinical trials have reported that early intensive blood pressure reduction can be a safe and feasible strategy for ICH, and have suggested a safe target range for systolic blood pressure. While new medical therapies associated with warfarin and non-vitamin K antagonist oral anticoagulants have been developed to treat ICH, recent trials have not been able to demonstrate the overall beneficial effects of surgical intervention on mortality and functional outcomes. However, some patients with ICH may benefit from surgical management in specific clinical contexts and/or at specific times. Furthermore, clinical trials for minimally invasive surgical evacuation methods are ongoing and may provide positive evidence. Upon understanding the current guidelines for the management of ICH, clinicians can administer appropriate treatment and attempt to improve the clinical outcome of ICH. The purpose of this review is to help in the decision-making of the medical and surgical management of ICH.
Collapse
Affiliation(s)
- Jun Yup Kim
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, College of Medicine, Seoul National University, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, College of Medicine, Seoul National University, Seongnam, Korea
| |
Collapse
|
39
|
Abstract
Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.
Collapse
|
40
|
Schreuder FHBM, Sato S, Klijn CJM, Anderson CS. Medical management of intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2017; 88:76-84. [PMID: 27852691 DOI: 10.1136/jnnp-2016-314386] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/14/2016] [Accepted: 10/25/2016] [Indexed: 02/06/2023]
Abstract
The global burden of intracerebral haemorrhage (ICH) is enormous. Developing evidence-based management strategies for ICH has been hampered by its diverse aetiology, high case fatality and variable cooperative organisation of medical and surgical care. Progress is being made through the conduct of collaborative multicentre studies with the large sample sizes necessary to evaluate therapies with realistically modest treatment effects. This narrative review describes the major consequences of ICH and provides evidence-based recommendations to support decision-making in medical management.
Collapse
Affiliation(s)
- Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.,Neurological and Mental Health Division, The George Institute for Global Health Australia, Sydney, New South Wales, Australia
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Craig S Anderson
- Neurological and Mental Health Division, The George Institute for Global Health Australia, Sydney, New South Wales, Australia.,The George Institute for Global Health China, Peking University Health Science Center, Beijing, China.,Central Clinical School, University of Sydney, Sydney, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
41
|
Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2016; 24:47-60. [PMID: 26646118 DOI: 10.1007/s12028-015-0221-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. In many of these diseases, there is an associated risk from bleeding because of standard VTE prophylaxis. There is a paucity of prospective studies examining different VTE prophylaxis strategies in the neurologically ill. The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.
Collapse
|
42
|
Casolla B, Tortuyaux R, Cordonnier C. Management of spontaneous intracerebral haemorrhages. Presse Med 2016; 45:e419-e428. [DOI: 10.1016/j.lpm.2016.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
43
|
Abstract
About half of patients survive intracerebral hemorrhage (ICH), but most are left with significant disability. Rehabilitation after ICH is the mainstay of treatment to reduce impairment, improve independence in activities, and return patients to meaningful participation in the community. The authors discuss the neuroplastic mechanisms underlying recovery in ICH, preclinical and clinical interventional studies to augment recovery, and the rehabilitative and medical management of post-ICH patients.
Collapse
Affiliation(s)
- Michael F Saulle
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, New York
| | - Heidi M Schambra
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, New York
| |
Collapse
|
44
|
Prophylactic heparin in acute intracerebral hemorrhage: a propensity score-matched analysis of the INTERACT2 study. Int J Stroke 2016; 11:549-56. [DOI: 10.1177/1747493016641113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/17/2016] [Indexed: 11/15/2022]
Abstract
Background Indication and timing of pharmacological venous thromboembolism prophylaxis in intracerebral hemorrhage patients is controversial. Aims To determine whether use of subcutaneous heparin during the first 7 days after spontaneous intracerebral hemorrhage increases risks of death and disability. Methods Data are from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) study. Patients with acute intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure were included; patients received subcutaneous heparin following local best practice standards of care. Multivariable logistic regression and propensity score matched analysis were used to determine associations of heparin use on death and disability (modified Rankin scale) at 90 days. Results In 2525 patients with available data, there were 465 (22.5%) who received subcutaneous heparin. They had higher death or major disability at 90 days in crude (odds ratio 2.29, 95% confidence interval 1.85–2.84; p < 0.001), adjusted (odds ratio 1.62, 95% confidence interval 1.26–2.09; p < 0.001) and propensity score matched (odds ratio 2.06, 95% confidence interval 1.53–2.77; p < 0.001) analyses. In propensity score matched analysis, heparin-treated patients had significant lower mortality (odds ratio 0.55, 95% CI 0.35–0.87; p = 0.01) but greater major disability (odds ratio 1.68, 95% confidence interval 1.25–2.28; p < 0.001) at 90 days. However, no mortality difference was found in analysis restricted to 48-hour survivors. Conclusions Use of subcutaneous heparin is associated with poor outcome in acute intracerebral hemorrhage, driven by increased residual disability. Despite the limitations of this study, and no clear relation of heparin with bleeding risk, we recommend careful consideration of the need for venous thromboembolism prophylaxis with heparin in intracerebral hemorrhage patients. Trial registration http://www.clinicaltrials.gov NCT00716079.
Collapse
|
45
|
Venous thromboembolism prevention during the acute phase of intracerebral hemorrhage. J Neurol Sci 2015; 358:3-8. [DOI: 10.1016/j.jns.2015.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/24/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022]
|
46
|
Trabert J, Steiner T. [Deep vein thrombosis and lung embolisms in patients with stroke: prevention and therapy]. DER NERVENARZT 2015; 85:1315-25. [PMID: 25186081 DOI: 10.1007/s00115-014-4031-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prevention and therapy of deep vein thrombosis and pulmonary embolisms in patients with acute stroke (ischemia and hemorrhage) represent a special challenge in the clinical routine. This article gives an overview on the epidemiology, risk factors and causes of deep vein thrombosis and pulmonary embolism in patients with acute stroke. The focus lies on the efficacy and safety of prophylactic treatment with compression stockings, compression devices and anticoagulants. Special therapeutic options in the event of symptomatic deep vein thrombosis and pulmonary embolisms in patients with intracerebral hemorrhage and increased risk of recurrent bleeding are presented.
Collapse
Affiliation(s)
- J Trabert
- Klinikum Frankfurt Höchst, Gotenstr. 6-8, 65929, Frankfurt a. M., Deutschland,
| | | |
Collapse
|
47
|
Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 1964] [Impact Index Per Article: 218.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
Collapse
|
48
|
Hsu JC, Hsieh CY, Yang YHK, Lu CY. Net clinical benefit of oral anticoagulants: a multiple criteria decision analysis. PLoS One 2015; 10:e0124806. [PMID: 25897861 PMCID: PMC4405347 DOI: 10.1371/journal.pone.0124806] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 03/19/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND This study quantitatively evaluated the comparative efficacy and safety of new oral anticoagulants (dabigatran, rivaroxaban, and apizaban) and warfarin for treatment of nonvalvular atrial fibrillation. We also compared these agents under different scenarios, including population with high risk of stroke and for primary vs. secondary stroke prevention. METHODS We used multiple criteria decision analysis (MCDA) to assess the benefit-risk of these medications. Our MCDA models contained criteria for benefits (prevention of ischemic stroke and systemic embolism) and risks (intracranial and extracranial bleeding). We calculated a performance score for each drug accounting for benefits and risks in comparison to treatment alternatives. RESULTS Overall, new agents had higher performance scores than warfarin; in order of performance scores: dabigatran 150 mg (0.529), rivaroxaban (0.462), apixaban (0.426), and warfarin (0.191). For patients at a higher risk of stroke (CHADS2 score≥3), apixaban had the highest performance score (0.686); performance scores for other drugs were 0.462 for dabigatran 150 mg, 0.392 for dabigatran 110 mg, 0.271 for rivaroxaban, and 0.116 for warfarin. Dabigatran 150 mg had the highest performance score for primary stroke prevention, while dabigatran 110 mg had the highest performance score for secondary prevention. CONCLUSIONS Our results suggest that new oral anticoagulants might be preferred over warfarin. Selecting appropriate medicines according to the patient's condition based on information from an integrated benefit-risk assessment of treatment options is crucial to achieve optimal clinical outcomes.
Collapse
Affiliation(s)
- Jason C. Hsu
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Yang Hsieh
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Stroke Center and Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Christine Y. Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, MA, United States of America
| |
Collapse
|
49
|
Abstract
Management of patients with an indication for long-term oral antithrombotic therapy who have an intracerebral hemorrhage (ICH) presents a therapeutic dilemma. Should antithrombotic therapy be resumed, and if so, when, using what agent, and for whom? There is no consensus for answers to these questions. In the absence of randomized trials, management of antithrombotic therapy after ICH is based on a combination of observational data, pathophysiologic concepts, and decision analysis. At the heart of the decision is an assessment of the individual patient's risk of thromboembolism off antithrombotic therapy versus risk of ICH recurrence on antithrombotic therapy.
Collapse
Affiliation(s)
- Allyson Zazulia
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110, USA.
| |
Collapse
|
50
|
Prabhakaran S, Herbers P, Khoury J, Adeoye O, Khatri P, Ferioli S, Kleindorfer DO. Is Prophylactic Anticoagulation for Deep Venous Thrombosis Common Practice After Intracerebral Hemorrhage? Stroke 2015; 46:369-75. [DOI: 10.1161/strokeaha.114.008006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Prophylactic anticoagulation for deep venous thrombosis prevention after intracerebral hemorrhage (ICH) is safe. Current guidelines recommend prophylactic anticoagulation after cessation of hematoma growth. We aimed to evaluate nationwide trends in deep venous thrombosis prophylaxis after ICH.
Methods—
In an analysis of the Premier database, we identified adult patients with ICH (
International Classification of Diseases
Ninth edition code 431) from 2006 to 2010 who survived to day 2 of hospitalization. We excluded those with trauma or who underwent craniotomy or angiography. We abstracted type of anticoagulant used and date of first administration. We used univariate statistics and multivariable logistic regression to assess factors associated with prophylactic anticoagulation after ICH.
Results—
Among 32 690 (mean age, 69.7 years; 50.1% men) patients with spontaneous ICH, 5395 (16.5%) patients received any prophylactic anticoagulation during the hospital stay. Among these patients, 2416 (44.8%) received prophylactic anticoagulation by day 2. The most commonly used agents were heparin (71.1%), enoxaparin (27.5%), and dalteparin (1.4%). The proportion of patients receiving prophylactic anticoagulation increased slightly during the study period from 14.3% to 18.0% (
P
<0.01 for trend). Use of prophylactic anticoagulation varied by geographic region (
P
<0.001) in the United States: Northeast (23.2%), South (19.0%), Midwest (10.8%), and West (9.8%). In multivariable analysis, geographic region remained an independent predictor of prophylactic anticoagulation.
Conclusions—
Less than 20% of patients with ICH receive anticoagulation for deep venous thrombosis in the United States. When used, the time to initiation is <2 days in less than half of the patients. Further study should focus on understanding variations in practice and emphasize guideline-driven care.
Collapse
Affiliation(s)
- Shyam Prabhakaran
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Patricia Herbers
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Jane Khoury
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Opeolu Adeoye
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Pooja Khatri
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Simona Ferioli
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Dawn O. Kleindorfer
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| |
Collapse
|