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Grainger BT, McFadyen JD, Tran H. Between a rock and a hard place: resumption of oral anticoagulant therapy after intracranial hemorrhage. J Thromb Haemost 2024; 22:594-603. [PMID: 37913910 DOI: 10.1016/j.jtha.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
Intracranial hemorrhage (ICH) is the most feared and lethal complication of oral anticoagulant (OAC) therapy. Resumption of OAC after ICH has long posed a challenge for clinicians, complicated by the expanding range of anticoagulant agents available in modern clinical practice, including direct OACs and, more recently, factor XI and XII inhibitors. A review of the current literature found support for resuming OAC in the majority of patients after ICH based on pooled retrospective data showing that resumption is associated with a lower risk of mortality and thromboembolism without a significantly increased risk of recurrent hemorrhage. The optimal time to resume OAC is less clear; however, the available evidence suggests that the composite risk of both recurrent hemorrhage and thromboembolism is likely minimized, somewhere between 4 and 6 weeks, after ICH in most patients. Specific considerations to guide the optimal resumption time in the individual patient include ICH location, mechanism, and anticoagulant class. Patients with mechanical heart valves and intracerebral malignancy represent high-risk groups who require more nuanced decision making. Here, we appraise the literature with the aim of providing a practical guide for clinicians while also discussing priorities for future investigation.
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Affiliation(s)
- Brian T Grainger
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Huyen Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Gorman J, Candeloro M, Schulman S. Anticoagulant Management and Outcomes in Nontraumatic Intracranial Hemorrhage Complicated by Venous Thromboembolism: A Retrospective Chart Review. Thromb Haemost 2023; 123:966-975. [PMID: 37015326 DOI: 10.1055/a-2068-6464] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND There are limited data on anticoagulant management of acute venous thromboembolism (VTE) after spontaneous intracranial hemorrhage (ICH). METHODS We reviewed retrospectively all cases diagnosed with VTE during hospitalization for spontaneous ICH at our center during 15 years. Anticoagulation management outcomes were (1) timing after ICH of anticoagulant initiation for VTE treatment, (2) use of immediate therapeutic dosing or stepwise dose escalation, and (3) the proportion achieving therapeutic dose. Primary clinical effectiveness outcome was recurrent VTE. Primary safety outcome was expanding ICH. RESULTS We analyzed 103 cases with VTE after 11 days (median; interquartile range [IQR]: 7-22) from the diagnosis of ICH. Forty patients (39%) achieved therapeutic anticoagulation 21.5 days (median; IQR: 14-34 days) from the ICH. Of those, 14 (35%; 14% of total) received immediately therapeutic dose and 26 (65%; 25% of total) had stepwise escalation. Anticoagulation was more aggressive in patients with VTE >14 days after admission versus those with earlier VTE diagnosis. Twenty-two patients (21%) experienced recurrent/progressive VTE-less frequently among patients with treatment escalation within 7 days or with no escalation than with escalation >7 days from the VTE. There were 19 deaths 6 days (median; IQR: 3.5-15) after the index VTE, with significantly higher in-hospital mortality rate among patients without escalation in anticoagulation. CONCLUSION Prompt therapeutic anticoagulation for acute VTE seems safe when occurring more than 14 days after spontaneous ICH. For VTE occurring earlier, it might also be safe with therapeutic anticoagulation, but stepwise dose escalation to therapeutic within a 7-day period might be preferable.
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Affiliation(s)
- Johnathon Gorman
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton Ontario, Canada
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton Ontario, Canada
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Juan MCY, Patel P, Zerona N, Christie A, Fendrikova Mahlay N, McLennan G, Tefera L. Increased incidence of venous thromboembolism associated with inferior vena cava filter placement in patients diagnosed with isolated calf deep vein thrombosis after intracranial hemorrhage or intracranial operation. J Thromb Thrombolysis 2023; 55:297-303. [PMID: 36525155 DOI: 10.1007/s11239-022-02736-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
In this study, we sought to investigate the effectiveness of inferior vena cava (IVC) filter placement in reducing the incidence of venous thromboembolism (VTE) in patients diagnosed with isolated calf deep vein thrombosis (DVT) after an intracranial hemorrhage or intracranial operation. A retrospective chart review (January 2000-December 2019) was performed to identify patients diagnosed with calf DVT after intracranial hemorrhage or intracranial operation. A total of 100 patients met the study criteria and were divided into groups based on treatment: IVC filter placement (n = 22), prophylactic anticoagulation (n = 42), or imaging surveillance (n = 36). Treatment-related complications were identified, and differences between groups in the primary endpoint (VTE occurrence after DVT diagnosis) were assessed using logistic regression. VTE occurred in 15 patients after calf DVT diagnosis. The rate of VTE was higher in the IVC filter group (9/22; 41%) than in the anticoagulation (2/42; 5%; p = 0.002) and surveillance (4/36; 11%; p = 0.013) groups. These treatment effects remained significant after adjustments were made for baseline characteristics (IVC filter vs anticoagulation, p = 0.009; IVC filter vs surveillance, p = 0.019). There was a single occurrence of pulmonary embolism in the surveillance group (3%). A single case of IVC filter thrombus was identified; no anticoagulation-related complications were reported. The findings of this study do not support IVC filter placement as a primary and solitary treatment for isolated calf DVT occurring after intracranial hemorrhage or intracranial operation.
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Affiliation(s)
- Michael C Y Juan
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Priyesh Patel
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Natalia Fendrikova Mahlay
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gordon McLennan
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Leben Tefera
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Cai Q, Zhang X, Chen H. Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review. Thromb J 2021; 19:93. [PMID: 34838069 PMCID: PMC8626951 DOI: 10.1186/s12959-021-00345-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.
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Affiliation(s)
- Qiyan Cai
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Zhang
- Respiratory Disease Department, Xinqiao Hospital, Chongqing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Rakotonoel RR, Rioufol G, Uhlrich W, Derimay F. Percutaneous atrial septal defect occlusion through thrombosed inferior vena cava filter. Clin Case Rep 2021; 9:e04350. [PMID: 34466235 PMCID: PMC8385180 DOI: 10.1002/ccr3.4350] [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: 01/13/2021] [Revised: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 11/11/2022] Open
Abstract
Thrombosed inferior vena cava (IVC) should not be considered as a limitation to femoral access for cardiac structural procedures. Reopening by angioplasty in the same procedural step is feasible and safe.
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Affiliation(s)
- Radotseheno Rolland Rakotonoel
- Cardiovascular Hospital and Claude Bernard University and Univ LyonCarMeN LaboratoryINSERMINRAINSA LyonUniversité Claude Bernard Lyon 1LyonFrance
- Cardiology UnitJoseph Raseta Befelatanana University HospitalAntananarivoMadagascar
| | - Gilles Rioufol
- Cardiovascular Hospital and Claude Bernard University and Univ LyonCarMeN LaboratoryINSERMINRAINSA LyonUniversité Claude Bernard Lyon 1LyonFrance
| | - William Uhlrich
- Cardiovascular Hospital and Claude Bernard University and Univ LyonCarMeN LaboratoryINSERMINRAINSA LyonUniversité Claude Bernard Lyon 1LyonFrance
| | - François Derimay
- Cardiovascular Hospital and Claude Bernard University and Univ LyonCarMeN LaboratoryINSERMINRAINSA LyonUniversité Claude Bernard Lyon 1LyonFrance
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Ajmeri AN, Zaheer K, McCorkle C, Amro A, Mustafa B. Treating Venous Thromboembolism Post Intracranial Hemorrhage: A Case Report. Cureus 2020; 12:e6746. [PMID: 32133268 PMCID: PMC7034755 DOI: 10.7759/cureus.6746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Venous thromboembolism (VTE) is a significant issue occurring due to genetic, acquired and circumstantial risk factors. Treatment is according to the clinical situation and judgment for long term anticoagulation based on individual risk. Anticoagulation after a history of a hemorrhagic stroke poses a therapeutic dilemma. We present a case of a 68-year-old male who presented with right-sided chest pain and shortness of breath. Workup included a CT that was positive for multiple right-sided pulmonary emboli (PE). The patient has a past medical history of Factor V Leiden Mutation, recurrent PE, and deep vein thrombosis (DVT). Two months prior he was diagnosed with a 1.3-cm intracranial hemorrhage (ICH) from multiple cavernous angiomas. At that time his warfarin was discontinued and an inferior vena cave (IVC) filter was placed. Facing the recent ICH and now multiple and recurrent PE, it was decided to resume anticoagulation based on ICH location. ICH from a deep source is likely a better characteristic that favors a resumption of anticoagulation. Our case will highlight that IVC filters cannot be solely relied upon in patients that are at high risk for thrombotic events with underlying genetic thrombophilia.
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Affiliation(s)
- Aman N Ajmeri
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Kamran Zaheer
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Colin McCorkle
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Ahmed Amro
- Cardiology, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Bisher Mustafa
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
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ACR Appropriateness Criteria® Radiologic Management of Venous Thromboembolism-Inferior Vena Cava Filters. J Am Coll Radiol 2019; 16:S214-S226. [DOI: 10.1016/j.jacr.2019.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/02/2023]
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Management of Acute Stroke in the Older Person. Geriatrics (Basel) 2017; 2:geriatrics2030027. [PMID: 31011037 PMCID: PMC6371128 DOI: 10.3390/geriatrics2030027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 07/21/2017] [Accepted: 07/31/2017] [Indexed: 12/27/2022] Open
Abstract
The majority of people who suffer a stroke are older adults. The last two decades have brought major progress in the diagnosis and management of stroke, which has led to significant reductions in mortality, long-term disability, and the need for institutional care. However, acute, interventional and preventative treatments have mostly been trialled in younger age groups. In this article we will provide an overview of the evidence for acute stroke treatments in relation to age, discuss special considerations in the older person, and contemplate patient choice, quality of life, and end-of-life-decisions.
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Iwamoto Y, Okamoto M, Hashimoto M, Fukuda Y, Uchimura Y, Iwamoto A, Matsumoto T, Iwasaki T, Kinoshita H, Ueda H, Kihara Y. Clinical outcomes and causes of death in Japanese patients with long-term inferior vena cava filter implants and deep vein thrombosis. J Cardiol 2014; 64:308-11. [PMID: 24679943 DOI: 10.1016/j.jjcc.2014.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 01/04/2014] [Accepted: 01/20/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE We assessed the causes of death and efficacy of permanent inferior vena cava (IVC) filters for preventing new pulmonary embolisms (PE) in Japanese deep vein thrombosis (DVT) patients with or without PE. METHODS AND SUBJECTS We studied the clinical outcomes during the follow-up period of 1 day to 9 years (median: 18 months; mean: 28 months) in 66 of 72 consecutive patients (44 with acute PE, 27 with intrapelvic DVT, and 1 with floating femoral vein thrombosis). Fifty of 66 patients received anticoagulant therapy after the filter placement. RESULTS Five patients died within 1 month (median 9 days) after the filter placement: three from recurrence of PE, one from cancer, and one from sepsis. Two of the three patients with recurrence of PE had preexisting intracardiac thrombi in the right atrium or main pulmonary artery before filter implantation. Ten patients died from the underlying disease (cancer: 7; brain hemorrhage: 1; amyotrophic lateral sclerosis: 1; pneumonia: 1) over 1 month after the filter placement (median follow-up period: 21 months). No new symptomatic PE recurrence was observed over 1 month after the filter placement. The 61 patients with long-term follow-up had no deterioration of DVT, and all the 31 patients who underwent multi-slice computed tomography showed no PE recurrence or filter thrombus occlusion, fracture, or migration. CONCLUSIONS Underlying diseases and preexisting intracardiac thrombi may be the determining factors for the prognosis of DVT patients. Permanent IVC filters with anticoagulant therapy may be effective for preventing death from new PE in Japanese DVT patients.
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Affiliation(s)
- Yumiko Iwamoto
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan; Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.
| | - Mitsunori Okamoto
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Masaki Hashimoto
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yukihiro Fukuda
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yuko Uchimura
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Akimichi Iwamoto
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Takeshi Matsumoto
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Toshitaka Iwasaki
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hiroki Kinoshita
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hironori Ueda
- Department of Cardiology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
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Weinberg I, Kaufman J, Jaff MR. Inferior Vena Cava Filters. JACC Cardiovasc Interv 2013; 6:539-47. [DOI: 10.1016/j.jcin.2013.03.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/20/2013] [Accepted: 03/01/2013] [Indexed: 01/29/2023]
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Abstract
Intracerebral haemorrhage (ICH) is the most devastating type of stroke and is a leading cause of disability and mortality. By contrast with advances in ischaemic stroke treatment, few evidence-based targeted treatments exist for ICH. Management of ICH is largely supportive, with strategies aimed at the limitation of further brain injury and the prevention of associated complications, which add further detrimental effects to an already lethal disease and jeopardise clinical outcomes. Complications of ICH include haematoma expansion, perihaematomal oedema with increased intracranial pressure, intraventricular extension of haemorrhage with hydrocephalus, seizures, venous thrombotic events, hyperglycaemia, increased blood pressure, fever, and infections. In view of the restricted number of therapeutic options for patients with ICH, improved surveillance is needed for the prevention of these complications, or, when this is not possible, early detection and optimum management, which could be effective in the reduction of adverse effects early in the course of stroke and in the improvement of prognosis. Further studies are needed to enhance the evidence-based recommendations for the management of this important clinical problem.
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Affiliation(s)
- Joyce S Balami
- Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
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