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Ueno H, Tokugawa J, Saito R, Yamashiro K, Tsutsumi S, Yamamoto M, Ueno Y, Mieno M, Yamamoto T, Hishii M, Yasumoto Y, Maruki C, Kondo A, Urabe T, Hattori N, Arai H, Tanaka R. Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry. Sci Rep 2024; 14:12009. [PMID: 38796624 PMCID: PMC11127931 DOI: 10.1038/s41598-024-62717-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/21/2024] [Indexed: 05/28/2024] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.
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Affiliation(s)
- Hideaki Ueno
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Rikizo Saito
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Satoshi Tsutsumi
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Munetaka Yamamoto
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Makoto Hishii
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Yukimasa Yasumoto
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Chikashi Maruki
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Ryota Tanaka
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan.
- Stroke Center and Division of Neurology, Department of Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Ghimire S, Shrestha S, Shrestha D, maharjan A, Jaiswal B, chaudhary P, Sherpa S. Anti-coagulants-induced intracranial hemorrhage managed with decompressive craniectomy: a case report of lesson learned. Ann Med Surg (Lond) 2024; 86:3036-3041. [PMID: 38694382 PMCID: PMC11060273 DOI: 10.1097/ms9.0000000000001996] [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: 01/31/2024] [Accepted: 02/24/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance Intracerebral haemorrhage (ICH) secondary to use of anti-coagulants is one of the fearsome complications. Haemorrhage within the intracranial space due to such anti-coagulants results in expansion of the intracranial bleeding despite the reversal of anti-coagulants. Hence, timely surgical intervention can be lifesaving. Case summary An elderly female who was undergoing management for her deranged coagulation parameters was found to be in a state of features suggestive of stroke. The patient was on regular anti-coagulants medication for her cardiology issues. Computed tomography (CT) scan showed intracranial haemorrhage, which underwent expansion on same day; hence decompressive craniectomy was done. During further stay in the ICU patient's Glasgow coma scale fluctuated but symptomatic improvement was noted. Anti-coagulants adjustment was made by a cardiologist and further, there was no expansion of intracranial bleeding within normal coagulation parameters. Discussion Anti-coagulants are rampantly used in several cases. Despite the several complications, there is a desperate need for such medications for the betterment of the patient's condition. Pharmacological management is a major modality in the reversal of oral anti-coagulants (OAC)-induced ICH, but in rare cases in the background of OACs-induced ICH, there occurs expansion of haemorrhage. Hence there is a need for neurosurgical intervention, whether it be minimally invasive surgery or decompressive craniectomy. Conclusion In the background of the low prevalence of OACs-induced ICH, there is an absence of a robust guiding treatment protocol. Furthermore, there exist minimal reported cases which underwent surgical intervention and resulted in a good prognosis.
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Affiliation(s)
- Sagun Ghimire
- Department of Neurosurgery, B and B Hospital, Gwarko, Lalitpur, Nepal
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Yang J, Jing J, Chen S, Liu X, Wang J, Pan C, Tang Z. Reversal and resumption of anticoagulants in patients with anticoagulant-associated intracerebral hemorrhage. Eur J Med Res 2024; 29:252. [PMID: 38659079 PMCID: PMC11044346 DOI: 10.1186/s40001-024-01816-5] [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: 09/27/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
The use of anticoagulants has become more frequent due to the progressive aging population and increased thromboembolic events. Consequently, the proportion of anticoagulant-associated intracerebral hemorrhage (AAICH) in stroke patients is gradually increasing. Compared with intracerebral hemorrhage (ICH) patients without coagulopathy, patients with AAICH may have larger hematomas, worse prognoses, and higher mortality. Given the need for anticoagulant reversal and resumption, the management of AAICH differs from that of conventional medical or surgical treatments for ICH, and it is more specific. Understanding the pharmacology of anticoagulants and identifying agents that can reverse their effects in the early stages are crucial for treating life-threatening AAICH. When patients transition beyond the acute phase and their vital signs stabilize, it is important to consider resuming anticoagulants at the right time to prevent the occurrence of further thromboembolism. However, the timing and strategy for reversing and resuming anticoagulants are still in a dilemma. Herein, we summarize the important clinical studies, reviews, and related guidelines published in the past few years that focus on the reversal and resumption of anticoagulants in AAICH patients to help implement decisive diagnosis and treatment strategies in the clinical setting.
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Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiahui Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Doeppner TR, Olbricht L, Maxhuni T, Alhaj Omar O, Sachs UJ, Juenemann MB, Huttner HB, Gerner ST. Urine-based point-of-care testing for factor-Xa-inhibitors in acute ischemic stroke patients: a feasibility study. Front Neurol 2023; 14:1330421. [PMID: 38162451 PMCID: PMC10756232 DOI: 10.3389/fneur.2023.1330421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) have become widely used in clinical practice for preventing thromboembolic events. Point-of-care testing methods, particularly those based on urine samples, offer a promising approach for rapid and accurate assessment of DOAC presence. This pilot study aims to evaluate the utility of a urine-based DOAC dipstick test as a point-of-care tool for identifying DOAB presence in acute ischemic stroke (AIS) or transient ischemic attack (TIA) patients. Patients and methods This prospective pilot study included patients with AIS/TIA eligible for DOAC-measurement. After exclusion of 3 patients, 23 patients with DOAC-intake (DOAC group; factor-Xa-inhibitors; n = 23) and 21 patients without DOAC-intake (control-group) remained for analyses. The urine-based DOAC dipstick test and parallel blood-based specific DOAC-level assessment were performed in all patients. Time-intervals of sampling urine/blood sampling and result of DOAC-test were recorded to analyze a potential time benefit based on dipstick evaluation. Results The urine-based DOAC dipstick test demonstrated high sensitivity (100%) and specificity (100%), correctly identifying all patients with anticoagulatory activity due to DOAC intake (i.e., anti-Xalevel ≥30 ng/mL). Moreover, the visual readout of the test provided semiquantitative information on drug-specific anti-Xa levels, showing a sensitivity of 83% and specificity of 93% to detect anti-Xa levels ≥120 ng/mL. The dipstick test exhibited a median time-benefit of 2:25 h compared to standard blood-based DOAC-level testing. Discussion The results of this pilot study underline the efficacy of urine-based point-of-care testing as a rapid and reliable method for assessing DOAC presence in patients with acute ischemic stroke. Conclusion The value of this tool for clinical decision-making in stroke management needs to be established in future trials.Clinical Trial Registration: Clinicaltrails.org identifier [NCT06037200].
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Affiliation(s)
- Thorsten R. Doeppner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Linus Olbricht
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Toska Maxhuni
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Omar Alhaj Omar
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Ulrich J. Sachs
- Division of Haemostaseology, University Hospital Giessen, Giessen, Germany
| | | | - Hagen B. Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps University Marburg and Justus Liebig University Giessen, Giessen, Germany
- Translational Neuroscience Network Giessen, Justus Liebig University Giessen, Giessen, Germany
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Cai H, Chen G, Hu W, Jiang C. Anticoagulant in atrial fibrillation patients with prior intracranial haemorrhage: a meta-analysis. Heart 2023; 109:1594-1600. [PMID: 37321829 DOI: 10.1136/heartjnl-2023-322492] [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: 02/02/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The benefit of resuming anticoagulation in atrial fibrillation (AF) patients with prior intracranial haemorrhage (ICH) and which anticoagulant to choose are controversial. SUMMARY OF REVIEW PubMed, Embase, Web of Science and the Cochrane Library were searched from their inception until 13 February 2022. Thirteen eligible articles (17 600 participants) were collected, including 11 real-world studies (n=17 296) and 2 randomised controlled trials (RCTs) (n=304). Compared with no anticoagulants, oral anticoagulation (OAC) was not associated with an increased risk of ICH recurrence (HR 0.85 (95% CI 0.57 to 1.25), p=0.41), but with a significantly increased risk of major bleeding (HR 1.66 (95% CI 1.20 to 2.30), p<0.01). Meanwhile, OAC was associated with a reduced risk of ischaemic stroke/systemic thromboembolism (IS/SE) (HR 0.54 (95% CI 0.42 to 0.70), p<0.01) and all-cause death (HR 0.38 (95% CI 0.28 to 0.52), p<0.01) compared with no anticoagulants. Furthermore, compared with warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with a significant reduction of ICH recurrence (HR 0.64 (95% CI 0.49 to 0.85), p<0.01), while the risk of IS/SE and all-cause mortality were comparable between warfarin and NOACs. CONCLUSIONS For patients with AF with prior ICH, OAC is associated with a significant reduction in IS/SE and all-cause mortality without increasing ICH recurrence, but may increase major bleeding risk. Compared with warfarin, NOACs had a better safety profile and comparable efficacy. Further larger RCTs are warranted to validate these findings.
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Affiliation(s)
- Huiya Cai
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guoquan Chen
- Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Wei Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chunjiao Jiang
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
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Haupenthal D, Schwab S, Kuramatsu JB. Hematoma expansion in intracerebral hemorrhage - the right target? Neurol Res Pract 2023; 5:36. [PMID: 37496094 PMCID: PMC10373350 DOI: 10.1186/s42466-023-00256-6] [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: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND The avoidance of hematoma expansion is the most important therapeutic goal during acute care of patients with intracerebral hemorrhage. Hematoma expansion occurs in up to 20-40% of patients and leads to poorer patient outcome in one of the most severe sub-types of stroke. MAIN TEXT At current, randomized controlled trials have failed to provide evidence for interventions that effectively improve functional outcome in patients with intracerebral hemorrhage. Hence, hematoma expansion may serve as important surrogate target that appears causally linked with a poorer prognosis. Therefore, reduction of hematoma expansion rates will eventually translate to improved patient outcome overall. Recent years have shed light on the importance of early and aggressive treatment in order to reduce the risk for hematoma expansion in these patients. Time measures and imaging markers have been identified that may allow patient selection at very high risk for hematoma expansion. CONCLUSIONS Refinements in patient selection may increase chance for randomized trials to show true benefit. Therefore, this current review article will critically evaluate and discuss available evidence associated with hematoma expansion in patients with intracerebral hemorrhage.
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Affiliation(s)
- David Haupenthal
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
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Cao H, Morotti A, Mazzacane F, Desser D, Schlunk F, Güttler C, Kniep H, Penzkofer T, Fiehler J, Hanning U, Dell'Orco A, Nawabi J. External Validation and Retraining of DeepBleed: The First Open-Source 3D Deep Learning Network for the Segmentation of Spontaneous Intracerebral and Intraventricular Hemorrhage. J Clin Med 2023; 12:4005. [PMID: 37373699 DOI: 10.3390/jcm12124005] [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: 05/10/2023] [Revised: 06/03/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The objective of this study was to assess the performance of the first publicly available automated 3D segmentation for spontaneous intracerebral hemorrhage (ICH) based on a 3D neural network before and after retraining. METHODS We performed an independent validation of this model using a multicenter retrospective cohort. Performance metrics were evaluated using the dice score (DSC), sensitivity, and positive predictive values (PPV). We retrained the original model (OM) and assessed the performance via an external validation design. A multivariate linear regression model was used to identify independent variables associated with the model's performance. Agreements in volumetric measurements and segmentation were evaluated using Pearson's correlation coefficients (r) and intraclass correlation coefficients (ICC), respectively. With 1040 patients, the OM had a median DSC, sensitivity, and PPV of 0.84, 0.79, and 0.93, compared to thoseo f 0.83, 0.80, and 0.91 in the retrained model (RM). However, the median DSC for infratentorial ICH was relatively low and improved significantly after retraining, at p < 0.001. ICH volume and location were significantly associated with the DSC, at p < 0.05. The agreement between volumetric measurements (r > 0.90, p > 0.05) and segmentations (ICC ≥ 0.9, p < 0.001) was excellent. CONCLUSION The model demonstrated good generalization in an external validation cohort. Location-specific variances improved significantly after retraining. External validation and retraining are important steps to consider before applying deep learning models in new clinical settings.
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Affiliation(s)
- Haoyin Cao
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili, 25123 Brescia, Italy
| | - Federico Mazzacane
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- U.C. Malattie Cerebrovascolari e Stroke Unit, IRCCS Fondazione Mondino, 27100 Pavia, Italy
| | - Dmitriy Desser
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Frieder Schlunk
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Christopher Güttler
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Tobias Penzkofer
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Andrea Dell'Orco
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neuroradiology, Charité School of Medicine and University Hospital Berlin, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, 10178 Berlin, Germany
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Das AS, Gökçal E, Regenhardt RW, Warren AD, Biffi A, Goldstein JN, Kimberly WT, Viswanathan A, Schwamm LH, Rosand J, Greenberg SM, Gurol ME. Clinical and neuroimaging risk factors associated with the development of intracerebral hemorrhage while taking direct oral anticoagulants. J Neurol 2022; 269:6589-6596. [PMID: 35997817 PMCID: PMC10947801 DOI: 10.1007/s00415-022-11333-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Intracerebral hemorrhage (ICH) associated with direct oral anticoagulant (DOAC) usage confers significant mortality/disability. We aimed to understand the clinical and neuroimaging features associated with developing ICH among DOAC users. METHODS Clinical and radiological data were collected from consecutive DOAC users with ICH (DOAC-ICH) and age-matched controls without ICH from a single referral center. The frequency/distribution of MRI markers of hemorrhage risk were assessed. Baseline demographics and neuroimaging markers were compared in univariate tests. Significant associations (p < 0.1) were entered into a multivariable regression model to determine predictors of ICH. RESULTS 86 DOAC-ICH and 94 ICH-free patients were included. Diabetes, coronary artery disease, prior ischemic stroke, smoking history, and antiplatelet usage were more common in ICH patients than ICH-free DOAC users. In the neuroimaging analyses, severe white matter hyperintensities (WMHs), lacunes, cortical superficial siderosis (cSS), and cerebral microbleeds (CMBs) were more common in the ICH cohort than the ICH-free cohort. In the multivariable regression, diabetes [OR 3.53 95% CI (1.05-11.87)], prior ischemic stroke [OR 14.80 95% CI (3.33-65.77)], smoking history [OR 3.08 95% CI (1.05-9.01)], CMBs [OR 4.07 95% CI (1.45-11.39)], and cSS [OR 39.73 95% CI (3.43-460.24)] were independently associated with ICH. CONCLUSIONS Risk factors including diabetes, prior stroke, and smoking history as well as MRI biomarkers including CMBs and cSS are associated with ICH in DOAC users. Although screening MRIs are not typically performed prior to initiating DOAC therapy, these data suggest that patients of high-hemorrhagic risk may be identified.
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Affiliation(s)
- Alvin S Das
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Elif Gökçal
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Robert W Regenhardt
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Andrew D Warren
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Alessandro Biffi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - W Taylor Kimberly
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA.
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Pfeilschifter W, Lindhoff-Last E, Alhashim A, Zydek B, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, von Heymann C, Birschmann I, Beyer-Westendorf J, Meybohm P, Greinacher A, Herrmann E. Intracranial bleeding under vitamin K antagonists or direct oral anticoagulants: results of the RADOA registry. Neurol Res Pract 2022; 4:16. [PMID: 35491419 PMCID: PMC9059415 DOI: 10.1186/s42466-022-00183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background and purpose The use of direct oral anticoagulants (DOAC) has increased sharply and DOAC are the oral anticoagulant therapy (OAT) of choice for the majority of patients with newly-diagnosed atrial fibrillation. Intracranial hemorrhage is the most severe adverse event of OAT. Systematic data on the course of intracranial hemorrhage under DOAC compared to vitamin K antagonists (VKA) are warranted to enable shared decision making in AF patients needing OAT. Methods This is a secondary analysis of the patients with intracranial bleedings from the prospective multicenter emergency department-based RADOA registry, which collected data on patients admitted with major bleeding while taking VKA or DOAC. The primary endpoint was in-hospital mortality until day 30. We evaluated hematoma volume and short-term clinical outcomes in relation to the extent of active OAT according to coagulation parameters and OAT plasma levels measured by UPLC-MS/MS. Results Of 193 patients with major bleeding, 109 (56.5%) had intracranial hemorrhage [52.3% intracerebral (ICH), 33.9% subdural (SDH), 11.0% subarachnoidal (SAH)]. 64 (58.7%) were on VKA and 45 (41.2%) were on DOAC. On admission, we could confirm active anticoagulation in 97.7% of VKA-treated patients based on either INR > 1.3 or phenprocoumon levels and in 75.8% of DOAC-treated patients based on DOAC levels. Patients suffering an intracranial hemorrhage under VKA showed significantly larger hematoma volumes and a higher in-hospital mortality. Especially in intracerebral hemorrhage, we observed a higher initial severity and numerically greater proportion of early changes towards palliative therapy under VKA, which coincided with a numerically higher case fatality. Conclusions We show significantly smaller hematoma volumes for ICH and SDH under DOAC in comparison to VKA and a significantly lower 30-day in-hospital mortality rate of DOAC-ICH, even before the introduction of specific antidotes. These data strongly support the use of DOAC whenever possible in patients requiring OAT. Trial Registration: http://www.clinicaltrials.gov; Unique identifier: NCT01722786.
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Affiliation(s)
- Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Klinikum Lueneburg, Bögelstr. 1, 21339, Lüneburg, Germany. .,Pharmazentrum Frankfurt, Institute of General Pharmacology and Toxicology, Goethe University, Frankfurt am Main, Germany. .,Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Edelgard Lindhoff-Last
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany.
| | - Ali Alhashim
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.,Neurology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Barbara Zydek
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis and Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1; Division Haematology, Dresden University Clinic, Dresden, Germany.,Department of Haematology and Oncology, Kings College, London, UK
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany.,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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10
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Assessment of CVD Risk Factors in Secondary Prevention after Ischemic Stroke Using the ICF. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063368. [PMID: 35329054 PMCID: PMC8948762 DOI: 10.3390/ijerph19063368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
Background: Patients after undergoing ischemic stroke have a high risk of further cardiovascular disease (CVD) incidents. Monitoring risk factors is critical to prevent the recurrence of CVD. Objective: The aim of the study was to determine differences in the incidence of risk factors for CVD in a post-ischemic stroke patient group (SG) compared to the control group, which had not undergone ischemic stroke (CG), and to characterize them using the ICF (International Classification of Functioning, Disability and Health) classification system. Materials and Methods: The incidence of risk factors for recurrent CVD events were retrospectively analyzed in 55 patients in SG and 55 patients in CG. The results were translated into categories from the ICF classification system. Results: Atrial fibrillation (p = 0.013), carotid artery stenosis > 50% (p < 0.001), LDL > 71 mg/dL (p < 0.001), heart rate > 80/min (p = 0.007), taking NOAC (p = 0.008) and NSAIDs (p < 0.001) as well as nicotinism (p = 0.001) were significantly more common in SG compared to CG. The value of the distribution of the total incidence of CVD risk factors were observed to be higher for SG than for CG. In SG, both for males (p < 0.001) and females (p < 0.001) more risk factors for recurrent CVD incidents were observed compared to CG. Conclusions: Patients in SG differ in the occurrence of risk factors for CVD event compared to CG. The use of a single tool, such as the ICF assessment sheet, can be useful in assessing and analyzing risk factors for recurrent CVD events. This may help to reduce the risk of subsequent CVD events in secondary prevention.
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11
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Hamad AS. Non-vitamin K antagonist oral anticoagulants for COVID-19 thrombosis. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.362812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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12
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Fanikos J, Goldstein JN, Lovelace B, Beaubrun AC, Blissett RS, Aragão F. Cost-effectiveness of andexanet alfa versus four-factor prothrombin complex concentrate for the treatment of oral factor Xa inhibitor-related intracranial hemorrhage in the US. J Med Econ 2022; 25:309-320. [PMID: 35168455 DOI: 10.1080/13696998.2022.2042106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM To conduct a cost-effectiveness analysis (CEA) on the use of andexanet alfa for the treatment of factor Xa inhibitor-related intracranial hemorrhage (ICH) from the US third-party payer and societal perspectives. METHODS CEA compared andexanet alfa to prothrombin complex concentrate for the treatment of patients receiving factor Xa inhibitors admitted to hospital inpatient care with an ICH. The model comprised two linked phases. Phase 1 utilized a decision tree to model the acute treatment phase (admission of a patient with ICH into intensive care for the first 30 days). Phase 2 modeled long-term costs and outcomes using three linked Markov models comprising the six health states defined by the modified Rankin score. RESULTS The analysis showed that the strategy of using andexanet alfa for the treatment of factor Xa inhibitor-related ICH is cost-effective, with incremental cost-effectiveness per quality-adjusted life-year gained of $35,872 from a third-party payer perspective and $40,997 from a societal perspective over 20 years. LIMITATIONS (1) Absence of head-to-head trials comparing therapies included in the economic model, (2) lack of comparative long-term data on treatment efficacy, and (3) bias resulting from the study designs of published literature. CONCLUSION Given these results, the use of andexanet alfa for the reversal of anticoagulation in patients with factor Xa inhibitor-related ICH may improve quality of life and is likely to be cost-effective in a US context.
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Affiliation(s)
| | | | | | | | | | - Filipa Aragão
- Maple Health Group, LLC, New York, NY, USA
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
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13
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Chuck CC, Kim D, Kalagara R, Rex N, Madsen TE, Mahmoud L, Thompson BB, Jones RN, Furie KL, Reznik ME. Modeling the Clinical Implications of Andexanet Alfa in Factor Xa Inhibitor-Associated Intracerebral Hemorrhage. Neurology 2021; 97:e2054-e2064. [PMID: 34556569 DOI: 10.1212/wnl.0000000000012856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/11/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Andexanet alfa was recently approved as a reversal agent for the factor Xa inhibitors (FXais) apixaban and rivaroxaban, but its impact on long-term outcomes in FXai-associated intracerebral hemorrhage (ICH) is unknown. We aimed to explore potential clinical implications of andexanet alfa in FXai-associated ICH in this simulation study. METHODS We simulated potential downstream implications of andexanet alfa across a range of possible hemostatic effects using data from a single center that treats FXai-associated ICH with prothrombin complex concentrate (PCC). We determined baseline probabilities of inadequate hemostasis across patients taking FXai and those not taking FXai via multivariable regression models and then determined the probabilities of unfavorable 3-month outcome (modified Rankin Scale score 4-6) using models comprising established predictors and each patient's calculated probability of inadequate hemostasis. We applied bootstrapping with model parameters from this derivation cohort to simulate a range of hemostatic improvements and corresponding outcomes and then calculated absolute risk reduction (relative to PCC) and projected number needed to treat (NNT) to prevent 1 unfavorable outcome. RESULTS Training models using real-world patients (n = 603 total, 55 on FXai) had good accuracy in predicting inadequate hemostasis (area under the curve [AUC] 0.78) and unfavorable outcome (AUC 0.78). Inadequate hemostasis was strongly associated with unfavorable outcome (odds ratio 4.5, 95% confidence interval [CI] 2.0-9.9) and occurred in 11.4% of patients taking FXai. Across simulated patients taking FXai comparable to those in A Study in Participants With Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors (ANNEXA-4) study, predicted absolute risk reduction of unfavorable outcome was 4.9% (95% CI 1.3%-7.8%) when the probability of inadequate hemostasis was reduced by 33% and 7.4% (95% CI 2.0%-11.9%) at 50% reduction, translating to projected NNT of 21 (cumulative cost $519,750) and 14 ($346,500), respectively. DISCUSSION Even optimistic simulated hemostatic effects suggest that the costs and potential benefits of andexanet alfa should be carefully considered. Placebo-controlled randomized trials are needed before its use can definitively be recommended.
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Affiliation(s)
- Carlin C Chuck
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Daniel Kim
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Roshini Kalagara
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Nathaniel Rex
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Tracy E Madsen
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Leana Mahmoud
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Bradford B Thompson
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Richard N Jones
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Karen L Furie
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence
| | - Michael E Reznik
- From the Departments of Neurology (C.C.C., D.K., N.R., B.B.T., R.N.J., K.L.F., M.R.), Emergency Medicine (T.E.M.), Neurosurgery (B.B.T., M.R.), and Psychiatry (R.N.J.), Brown University, Alpert Medical School, Providence, RI; Icahn School of Medicine at Mount Sinai (R.K.), New York, NY; and Department of Pharmacy (L.M.), Rhode Island Hospital, Providence.
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14
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Huttner HB, Gerner ST, Kuramatsu JB, Connolly SJ, Beyer-Westendorf J, Demchuk AM, Middeldorp S, Zotova E, Altevers J, Andersohn F, Christoph MJ, Yue P, Stross L, Schwab S. Hematoma Expansion and Clinical Outcomes in Patients With Factor-Xa Inhibitor-Related Atraumatic Intracerebral Hemorrhage Treated Within the ANNEXA-4 Trial Versus Real-World Usual Care. Stroke 2021; 53:532-543. [PMID: 34645283 DOI: 10.1161/strokeaha.121.034572] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE It is unestablished whether andexanet alfa, compared with guideline-based usual care including prothrombin complex concentrates, is associated with reduced hematoma expansion (HE) and mortality in patients with factor-Xa inhibitor-related intracerebral hemorrhage (ICH). We compared the occurrence of HE and clinical outcomes in patients treated either with andexanet alfa or with usual care during the acute phase of factor-Xa inhibitor-related ICH. METHODS Data were extracted from the multicenter, prospective, single-arm ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) and a multicenter observational cohort study, RETRACE-II (German-Wide Multicenter Analysis of Oral Anticoagulant-Associated Intracerebral Hemorrhage - Part Two). HE was based on computed tomography scans performed within 36 hours from baseline imaging. Inverse probability of treatment weighting was performed to adjust for baseline comorbidities and ICH severity. Patients presenting with atraumatic ICH while receiving apixaban or rivaroxaban within 18 hours of admission were included. Patients with secondary ICH or not fulfilling the inclusion criteria for the ANNEXA-4 trial were excluded. We compared ANNEXA-4 patients, who received andexanet alfa for hemostatic treatment, with RETRACE-II patients who were treated with usual care, primarily administration of prothrombin complex concentrates. Primary outcome was rate of HE defined as relative increase of ≥35%. Secondary outcomes comprised mean absolute change in hematoma volume, as well as in-hospital mortality and functional outcome. RESULTS Overall, 182 patients with factor-Xa inhibitor-related ICH (85 receiving andexanet alfa versus 97 receiving usual care) were selected for analysis. There were no relevant differences regarding demographic or clinical characteristics between both groups. HE occurred in 11 of 80 (14%) andexanet alfa patients compared with 21 of 67 (36%) usual care patients (adjusted relative risk, 0.40 [95% CI, 0.20-0.78]; P=0.005), with a reduction in mean overall hematoma volume change of 7 mL. There were no statistically significant differences among in-hospital mortality or functional outcomes. Sensitivity analysis including only usual care patients receiving prothrombin complex concentrates demonstrated consistent results. CONCLUSIONS As compared with usual care, andexanet alfa was associated with a lower rate of HE in atraumatic factor-Xa inhibitor-related ICH, however, without translating into significantly improved clinical outcomes. A comparative trial is needed to confirm the benefit on limiting HE and to explore clinical outcomes across patient subgroups and by time to treatment.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., S.T.G., J.B.K., S.S.).,Department of Neurology, University Hospital Giessen, Germany (H.B.H.)
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., S.T.G., J.B.K., S.S.)
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., S.T.G., J.B.K., S.S.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Canada (S.J.C., E.Z.)
| | - Jan Beyer-Westendorf
- Department of Medicine, Dresden University Clinic Fetscherstr, Germany (J.B.-W.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Canada. (A.M.D.).,Department of Radiology, University of Calgary, Canada. (A.M.D.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (S.M.)
| | - Elena Zotova
- Population Health Research Institute, McMaster University, Canada (S.J.C., E.Z.)
| | | | | | - Mary J Christoph
- Portola Pharmaceuticals, Inc (now Alexion, AstraZeneca Rare Disease), Boston, MA (M.J.C.)
| | - Patrick Yue
- Former employee of Portola Pharmaceuticals, Inc (now Alexion, AstraZeneca, Rare Disease), Boston, MA (P.Y., L.S.)
| | - Leonhard Stross
- Former employee of Portola Pharmaceuticals, Inc (now Alexion, AstraZeneca, Rare Disease), Boston, MA (P.Y., L.S.)
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., S.T.G., J.B.K., S.S.)
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15
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Sasannejad C, Sheth KN. Anticoagulation in Acute Neurological Disease. Semin Neurol 2021; 41:530-540. [PMID: 34619779 DOI: 10.1055/s-0041-1733793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Liu YB, Kuo LT, Chen CH, Kung WM, Tsai HH, Chou SC, Yang SH, Wang KC, Lai DM, Huang APH. Surgery for Coagulopathy-Related Intracerebral Hemorrhage: Craniotomy vs. Minimally Invasive Neurosurgery. Life (Basel) 2021; 11:life11060564. [PMID: 34203953 PMCID: PMC8232628 DOI: 10.3390/life11060564] [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] [Received: 05/11/2021] [Revised: 06/03/2021] [Accepted: 06/09/2021] [Indexed: 02/05/2023] Open
Abstract
Coagulopathy-related intracerebral hemorrhage (ICH) is life-threatening. Recent studies have shown promising results with minimally invasive neurosurgery (MIN) in the reduction of mortality and improvement of functional outcomes, but no published data have recorded the safety and efficacy of MIN for coagulopathy-related ICH. Seventy-five coagulopathy-related ICH patients were retrospectively reviewed to compare the surgical outcomes between craniotomy (n = 52) and MIN (n = 23). Postoperative rebleeding rates, morbidity rates, and mortality at 1 month were analyzed. Postoperative Glasgow Outcome Scale Extended (GOSE) and modified Rankin Scale (mRS) scores at 1 year were assessed for functional outcomes. Morbidity, mortality, and rebleeding rates were all lower in the MIN group than the craniotomy group (8.70% vs. 30.77%, 8.70% vs. 19.23%, and 4.35% vs. 23.08%, respectively). The 1-year GOSE score was significantly higher in the MIN group than the craniotomy group (3.96 ± 1.55 vs. 3.10 ± 1.59, p = 0.027). Multivariable logistic regression analysis also revealed that MIN contributed to improved GOSE (estimate: 0.99650, p = 0.0148) and mRS scores (estimate: -0.72849, p = 0.0427) at 1 year. MIN, with low complication rates and improved long-term functional outcome, is feasible and favorable for coagulopathy-related ICH. This promising result should be validated in a large-scale prospective study.
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Affiliation(s)
- Yen-Bo Liu
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (C.-H.C.); (H.-H.T.)
| | - Woon-Man Kung
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei 11114, Taiwan;
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (C.-H.C.); (H.-H.T.)
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei 10617, Taiwan
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan;
| | - Shih-Hung Yang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
| | - Kuo-Chuan Wang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
| | - Dar-Ming Lai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10617, Taiwan; (Y.-B.L.); (L.-T.K.); (S.-H.Y.); (K.-C.W.); (D.-M.L.)
- Correspondence: ; Tel.: +886-928-778-778
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Risk Factors for the Recurrence of CVD Incidents in Post-Stroke Patients over a 5-Year Follow-Up Period Based on the ICF Classification. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116021. [PMID: 34205106 PMCID: PMC8199949 DOI: 10.3390/ijerph18116021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Stroke is a strong risk factor for recurrent cardiovascular disease (CVD) incidents. The risk of post-stroke CVD incidents can be reduced by eliminating the most relevant risk factors. The aim of the study was to compare the incidence of recurrent CVD events and to determine the quantitative and qualitative differences in CVD risk factors over the 5-year follow-up period in patients with ischemic stroke (IS) and haemorrhagic stroke (ICH) with the use of ICF classification categories to present these differences. Materials and Methods: The study was retrospective. The study groups included 55 post-IS patients and 47 post-ICH patients. The results were translated into the categories from the International Classification of Functioning, Disability and Health (ICF) classification. Results: As compared to post-ICH patients, post-IS patients were significantly more frequently observed to have recurrent CVD incidents (p < 0.001), including fatal CVD incidents (p = 0.003). More risk factors in total were identified in both post-IS patients (p = 0.031) and post-ICH patients (p = 0.002) who had a recurrent CVD incident. Post-IS patients were more often found to have arterial blood pressure higher than 140/90 mmHg (p = 0.045). On the other hand, post-ICH patients were more frequently observed to have carotid artery stenosis in the range of 50–69% (p = 0.028) and an eGFR of <15 mL/min/1.73 m2 (p = 0.001). Conclusions: The type of primary stroke determines the type and incidence of risk factors as well as the recurrence rate of CVD incidents over a 5-year follow-up period. Patients after IS have a higher risk of recurrence of CVD events, including fatal ones in the 5-year follow-up compared to patients after ICH. In addition, post-IS patients who have a recurrent CVD event over a 5-year follow-up have more risk factors for a CVD event than ICH. The ICF classification can be useful for assessing and analysing risk factors for recurrent CVD incidents, which can help to improve the effectiveness of secondary prevention.
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Peng J, Volbers B, Sprügel MI, Hoelter P, Engelhorn T, Jiang Y, Kuramatsu JB, Huttner HB, Dörfler A, Schwab S, Gerner ST. Influence of Early Enteral Nutrition on Clinical Outcomes in Neurocritical Care Patients With Intracerebral Hemorrhage. Front Neurol 2021; 12:665791. [PMID: 33959093 PMCID: PMC8093818 DOI: 10.3389/fneur.2021.665791] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Early enteral nutrition (EEN) represents the current standard of care for patients treated in general intensive care units (ICU). Specific nutritional recommendations for patients receiving dedicated neurocritical care are not established. This study investigated associations of EEN with clinical outcomes for patients suffering from intracerebral hemorrhage treated at a neurological ICU (NICU). Methods: This retrospective cohort study included patients admitted to the NICU with atraumatic ICH over a 4-year period. Nutritional data, demographic, clinical, radiological, and laboratory characteristics were assessed. EEN was defined as any enteral nutrition within 48 hours after admission. Comparisons were undertaken for patients with EEN vs. those without, further propensity score (PS) matching (caliper 0.2; one: many) was used to account for baseline imbalances. Primary outcome was the modified Rankin Scale (0–3 = favorable, 4–6 = unfavorable) at 12 months, secondary outcomes comprised perihemorrhagic edema (PHE) volume, infectious complications during the hospital stay, and mRS at 3 months, as well as mortality rates at 3 and 12 months. Results: Of 166 ICH-patients treated at the NICU, 51 (30.7%) patients received EEN, and 115 (69.3%) patients received no EEN (nEEN). After propensity score matching, calories delivered from enteral nutrition (EEN 161.4 [106.4–192.3] kcal/day vs. nEEN 0.0 [0.0–0.0], P < 0.001) and the total calories (EEN 190.0 [126.0–357.0] kcal/day vs. nEEN 33.6 [0.0–190.0] kcal/day, P < 0.001) were significantly different during the first 48 h admitted in NICU. Functional outcome at 12 months (mRS 4–6, EEN 33/43 [76.7%] vs. nEEN, 49/64 [76. 6%]; P = 1.00) was similar in the two groups. There were neither differences in mRS at 3 months, nor in mortality rates at 3 and 12 months between the two groups. EEN did not affect incidence of infective complications or gastrointestinal adverse events during the hospital stay; however, EEN was associated with significantly less extent of PHE evolution [maximum absolute PHE (OR 0.822, 95% CI 0.706–0.957, P = 0.012); maximum relative PHE (OR 0.784, 95% CI 0.646–0.952, P = 0.014)]. Conclusion: In our study, EEN was associated with reduced PHE in ICH-patients treated at a NICU. However, this observation did not translate into improved survival or functional outcome at 3 and 12 months.
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Affiliation(s)
- Jianhua Peng
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bastian Volbers
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Lucki M, Chlebuś E, Wareńczak A, Lisiński P. The ICF Classification System to Assess Risk Factors for CVD in Secondary Prevention after Ischemic Stroke and Intracerebral Hemorrhage. ACTA ACUST UNITED AC 2021; 57:medicina57030190. [PMID: 33668265 PMCID: PMC7996308 DOI: 10.3390/medicina57030190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 11/11/2022]
Abstract
Background and objectives: Patients with a history of prior stroke have a high risk for subsequent cardiovascular events (CVD). Therefore, the implementation of an effective strategy to reduce risk factors and thereby improve secondary prevention outcomes is crucial in this patient population. The aim of this study was to determine differences in the incidence of risk factors for recurrent CVD events based on clinical type of prior stroke and to characterize them using the ICF (International Classification of Functioning, Disability and Health) classification system. Materials and Methods: The incidence of risk factors for recurrent CVD events were retrospectively analyzed in 109 patients with a history of ischemic stroke (IS) and 80 patients with a history of intracerebral hemorrhage (ICH) within 14 days poststroke. Results: Atrial fibrillation/flutter (p = 0.031), >70% carotid artery stenosis (p = 0.004), blood pressure >140/90 mmHg (p = 0.025), blood HbA1c levels >7% (p = 0.002), smoking (p = 0.026) and NSAID (nonsteroidal anti-inflammatory drug) use (p < 0.001) were significantly more common in patients with a history of ischemic stroke. However, liver function test abnormalities were observed more commonly in patients with a history of hemorrhagic stroke (p = 0.025). Conclusions: The incidence and type of risk factors for recurrent CVD events vary according to the clinical type of prior stroke. The ICF classification system is a useful tool for evaluating these risk factors. This may help reduce the risk of subsequent CVD events.
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Affiliation(s)
- Mateusz Lucki
- Department of Cardiology, Hospital Center of the Jelenia Góra Valley, 58-506 Jelenia Góra, Poland
- Correspondence: ; Tel.: +48-506-474-083
| | - Ewa Chlebuś
- Department of Rehabilitation and Physiotherapy, University of Medical Sciences, 60-545 Poznań, Poland; (E.C.); (A.W.); (P.L.)
| | - Agnieszka Wareńczak
- Department of Rehabilitation and Physiotherapy, University of Medical Sciences, 60-545 Poznań, Poland; (E.C.); (A.W.); (P.L.)
| | - Przemysław Lisiński
- Department of Rehabilitation and Physiotherapy, University of Medical Sciences, 60-545 Poznań, Poland; (E.C.); (A.W.); (P.L.)
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Kulesh AA. Current approaches to diagnosing in intracerebral hemorrhage. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2020. [DOI: 10.14412/2074-2711-2020-2-4-11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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21
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Sembill JA, Kuramatsu JB, Gerner ST, Sprügel MI, Roeder SS, Madžar D, Hagen M, Hoelter P, Lücking H, Dörfler A, Schwab S, Huttner HB. Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage. Ann Clin Transl Neurol 2020; 7:363-374. [PMID: 32133793 PMCID: PMC7086015 DOI: 10.1002/acn3.51001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/10/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Hematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobar ICH. METHODS Pooled analysis of individual patient data between January 2006 and December 2015 from a German-wide cohort study (RETRACE, I + II) investigating ICH related to oral anticoagulants (OAC) at 22 participating centers, and from one single-center registry (UKER-ICH) investigating non-OAC-ICH patients. Altogether, 1954 supratentorial ICH patients were eligible for outcome analyses, which were separately conducted or controlled for OAC, that is, vitamin-K-antagonists (VKA, n = 1186) and non-vitamin-K-antagonist-oral-anticoagulants (NOAC, n = 107). Confounding was addressed using propensity score matching, cox regression modeling and multivariate modeling. Main outcomes were occurrence, extent, and timing of HE (>33%/>6 mL) and its association with 3-month functional outcome. RESULTS Occurrence of HE was not different after deep versus lobar ICH in patients with non-OAC-ICH (39/356 [11.0%] vs. 36/305 [11.8%], P = 0.73), VKA-ICH (249/681 [36.6%] vs. 183/505 [36.2%], P = 0.91), and NOAC-ICH (21/69 [30.4%] vs. 12/38 [31.6%], P = 0.90). HE extent did not differ after non-OAC-ICH (deep:+59% [40-122] vs. lobar:+74% [37-124], P = 0.65), but both patients with VKA-ICH and NOAC-ICH showed greater HE extent after deep ICH [VKA-ICH, deep: +94% [54-199] vs. lobar: +56% [35-116], P < 0.001; NOAC-ICH, deep: +74% [56-123] vs. lobar: +40% [21-49], P = 0.001). Deep compared to lobar ICH patients had higher HE hazard during first 13.5 h after onset (Hazard ratio [HR]: 1.85 [1.03-3.31], P = 0.04), followed by lower hazard (13.5-26.5 h, HR: 0.46 [0.23-0.89], P = 0.02), and equal hazard thereafter (HR: 0.96 [0.56-1.65], P = 0.89). Odds ratio for unfavorable outcome was higher after HE in deep (4.31 [2.71-6.86], P < 0.001) versus lobar ICH (2.82 [1.71-4.66], P < 0.001), and only significant after small-medium (1st volume-quarter, deep: 3.09 [1.52-6.29], P < 0.01; lobar: 3.86 [1.35-11.04], P = 0.01) as opposed to large-sized ICH (4th volume-quarter, deep: 1.09 [0.13-9.20], P = 0.94; lobar: 2.24 [0.72-7.04], P = 0.17). INTERPRETATION HE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC-ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small-medium compared to large-sized bleedings.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany
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An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants. Adv Hematol 2020; 2020:7636104. [PMID: 32231703 PMCID: PMC7097770 DOI: 10.1155/2020/7636104] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/26/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding. The administration of reversal agents should be considered in patients on NOAC's with major bleeding manifestations (life-threatening bleeding, or major uncontrolled bleeding), or those who require rapid anticoagulant reversal for an emergent surgical procedure. The Food and Drug Administration (FDA) has approved two reversal agents for NOACs: idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) have released an updated guideline for the management of patients with atrial fibrillation that provides indications for the use of these reversal agents. In addition, the final results of the ANNEXA-4 study that evaluated the efficacy and safety of andexanet alfa were recently published. Several agents are in different phases of clinical trials, and among them, ciraparantag has shown promising results. However, their higher cost and limited availability remains a concern. Here, we provide a brief review of the available reversal agents for NOACs (nonspecific and specific), recent updates on reversal strategies, lab parameters (including point-of-care tests), NOAC resumption, and agents in development.
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23
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Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Karapanayiotides T, Sharaf A, Chang J, Kargiotis O, Pandhi A, Palaiodimou L, Schroeder C, Tsantes A, Boviatsis E, Mehta C, Serdari A, Vadikolias K, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation. J Neurol 2019; 267:1053-1062. [PMID: 31848737 DOI: 10.1007/s00415-019-09678-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. METHODS We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a "Favorable" indication for anticoagulation; if negative, "Unfavorable". RESULTS We enrolled 357 patients [59% men, median age 76 (68-82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66-80) vs 78 (73-84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3-4) vs 5(4-6), p < 0.001]. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%, p = 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease. CONCLUSIONS In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aboubakar Sharaf
- Department of Neurology, Essentia Health-Duluth Clinic, Duluth, MN, USA
| | - Jason Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christoph Schroeder
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit (A.T.), School of Medicine, "Attikon" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, School of Medicine, "Attikon University Hospital", National and Kapodistrian University of Athens, Athens, Greece
| | - Chandan Mehta
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Aspasia Serdari
- Department of Child and Adolescent Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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