1
|
Joo H, Bae J, Park JW, Lee BJ, Lee BD, Bu Y. Modified Protocol to Enable the Study of Hemorrhage and Hematoma in a Traumatic Brain Injury Mouse Model. Front Neurol 2021; 12:717513. [PMID: 34650505 PMCID: PMC8505523 DOI: 10.3389/fneur.2021.717513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/27/2021] [Indexed: 11/13/2022] Open
Abstract
To date, many studies using the controlled cortical impact (CCI) mouse model of traumatic brain injury (TBI) have presented results without presenting the pathophysiology of the injury-core itself or the temporal features of hemorrhage (Hrr). This might be owing to the removal of the injury-core during the histological procedure. We therefore developed a modified protocol to preserve the injury-core. The heads of mice were obtained after perfusion and were post-fixed. The brains were then harvested, retaining the ipsilateral skull bone; these were post-fixed again and sliced using a cryocut. To validate the utility of the procedure, the temporal pattern of Hrr depending on the impacting depth was analyzed. CCI-TBI was induced at the following depths: 1.5 mm (mild Hrr), 2.5 mm (moderate Hrr), and 3.5 mm (severe Hrr). A pharmacological study was also conducted using hemodynamic agents such as warfarin (2 mg/kg) and coagulation factor VIIa (Coa-VIIa, 1 mg/kg). The current protocol enabled the visual observation of the Hrr until 7 days. Hrr peaked at 1–3 days and then decreased to the normal range on the seventh day. It expanded from the affected cortex (mild) to the periphery of the hippocampus (moderate) and the brain ventricle (severe). Pharmacological studies showed that warfarin pre-treatment produced a massively increased Hrr, concurrent with the highest mortality rate and brain injury. Coa-VIIa reduced the side effects of warfarin. Therefore, these results suggest that the current method might be suitable to conduct studies on hemorrhage, hematoma, and the injury-core in experiments using the CCI-TBI mouse model.
Collapse
Affiliation(s)
- Hyejin Joo
- Department of Science in Korean Medicine, Graduate School, Kyung Hee University, Seoul, South Korea
| | - Jinhyun Bae
- Department of Herbal Pharmacology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Jae-Woo Park
- Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Beom-Joon Lee
- Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Byoung Dae Lee
- Department of Physiology, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Youngmin Bu
- Department of Herbal Pharmacology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| |
Collapse
|
2
|
Chu H, Gao Z, Huang C, Dong J, Tang Y, Dong Q. Relationship Between Hematoma Expansion Induced by Hypertension and Hyperglycemia and Blood-brain Barrier Disruption in Mice and Its Possible Mechanism: Role of Aquaporin-4 and Connexin43. Neurosci Bull 2020; 36:1369-1380. [PMID: 32623691 PMCID: PMC7674541 DOI: 10.1007/s12264-020-00540-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/24/2020] [Indexed: 12/24/2022] Open
Abstract
We aimed to select an optimized hematoma expansion (HE) model and investigate the possible mechanism of blood-brain barrier (BBB) damage in mice. The results showed that HE occurred in the group with hypertension combined with hyperglycemia (HH-HE) from 3 to 72 h after intracerebral hemorrhage; this was accompanied by neurological deficits and hardly influenced the survival rate. The receiver operating characteristic curve suggested the criterion for this model was hematoma volume expansion ≥ 45.0%. Meanwhile, HH-HE aggravated BBB disruption. A protector of the BBB reduced HH-HE, while a BBB disruptor induced a further HH-HE. Aquaporin-4 (AQP4) knock-out led to larger hematoma volume and more severe BBB disruption. Furthermore, hematoma volume and BBB disruption were reduced by multiple connexin43 (Cx43) inhibitors in the wild-type group but not in the AQP4 knock-out group. In conclusion, the optimized HE model is induced by hypertension and hyperglycemia with the criterion of hematoma volume expanding ≥ 45.0%. HH-HE leads to BBB disruption, which is dependent on AQP4 and Cx43.
Collapse
Affiliation(s)
- Heling Chu
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China
- Department of Neurology, North Huashan Hospital, Fudan University, Shanghai, 201907, China
| | - Zidan Gao
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Chuyi Huang
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Jing Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China.
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200040, China.
| |
Collapse
|
3
|
Schlunk F, Böhm M, Boulouis G, Qin T, Arbel M, Tamim I, Fischer P, Bacskai BJ, Frosch MP, Endres M, Greenberg SM, Ayata C. Secondary Bleeding During Acute Experimental Intracerebral Hemorrhage. Stroke 2019; 50:1210-1215. [PMID: 31009358 PMCID: PMC6478448 DOI: 10.1161/strokeaha.118.021732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose- Mechanisms contributing to acute hematoma growth in intracerebral hemorrhage are not well understood. Neuropathological studies suggest that the initial hematoma may create mass effect that can tear vessels in the vicinity by shearing, causing further bleeding and hematoma growth. Methods- To test this in mice, we simulated initial intracerebral hemorrhage by intrastriatal injection of a liquid polymer that coagulates upon contact with tissue and measured the presence and volume of bleeding secondary to the mass effect using Hemoglobin ELISA 15 minutes after injection. Results- Secondary hemorrhage occurred in a volume-dependent (4, 7.5, or 15 μL of polymer) and rate-dependent (0.05, 0.5, or 5 μL/s) manner. Anticoagulation (warfarin or dabigatran) exacerbated the secondary hemorrhage volume. In a second model of hematoma expansion, we confirmed that intrastriatal whole blood injection (15 μL, 0.5 μL/s) also caused secondary bleeding, using acute Evans blue extravasation as a surrogate. Anticoagulation once again exacerbated secondary hemorrhage after intrastriatal whole blood injection. Secondary hemorrhage directly and significantly correlated with arterial blood pressures in both nonanticoagulated and anticoagulated mice, when modulated by phenylephrine or labetalol. Conclusions- Our study provides the first proof of concept for secondary vessel rupture and bleeding as a potential mechanism for intracerebral hematoma growth.
Collapse
Affiliation(s)
- Frieder Schlunk
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité Universitätsmedizin, Berlin, Germany
| | - Maximilian Böhm
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Gregoire Boulouis
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tao Qin
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Michal Arbel
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Isra Tamim
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Paul Fischer
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Brian J. Bacskai
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Matthew P. Frosch
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité Universitätsmedizin, Berlin, Germany
| | - Steven M. Greenberg
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
4
|
Foerch C, Schäfer JH, Pfeilschifter W, Bohmann F. [Direct oral anticoagulants and acute stroke : Insights into translational research studies]. Nervenarzt 2017; 88:642-651. [PMID: 28188404 DOI: 10.1007/s00115-017-0282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In recent years a considerable number of translational research studies on intracerebral hemorrhage and ischemic stroke have been published, which are characterized by a particular proximity to practical clinical questions. Animal research has provided insights into the pathophysiological processes and therapy effects, which have so far only been insufficiently investigated in clinical studies. This includes the effectiveness of a rapid reversal of anticoagulation in cases of anticoagulation-associated intracerebral hemorrhage and the safety of thrombolytic treatment in ischemic stroke occurring during treatment with anticoagulants. With the approval of the direct oral anticoagulants these problems have become of particular contemporary relevance. Of course, results from experimental translational studies on stroke cannot be directly translated into clinical routine. Nevertheless, these investigations help to understand the underlying processes and mechanisms and provide proof of concept data for new treatment strategies. This review summarizes the most relevant results in this field of research with a particular focus on practical clinical questions.
Collapse
Affiliation(s)
- C Foerch
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland.
| | - J H Schäfer
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - W Pfeilschifter
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - F Bohmann
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| |
Collapse
|
5
|
DeLoughery E, Avery B, DeLoughery TG. Retrospective study of rFVIIa, 4-factor PCC, and a rFVIIa and 3-factor PCC combination in improving bleeding outcomes in the warfarin and non-warfarin patient. Am J Hematol 2016; 91:705-8. [PMID: 27074566 DOI: 10.1002/ajh.24384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 11/07/2022]
Abstract
In case of severe bleeding, the physician must rapidly and effectively halt bleeding without the risk of thromboembolic complications. Despite widespread use, no study has directly compared recombinant activated factor VII (rFVIIa), the rFVIIa and 3-factor prothrombin complex concentrate (PCC) combination ("combination"), and 4-factor PCC on their effectiveness in improving patient outcomes. This study examined the medical records of 299 patients, 65.2% on warfarin prior to admission, who received these hemostatic agents and were admitted to an ICU or through the emergency department at Oregon Health & Science University. Mortality, length of stay, change in international normalized ratio (INR), plasma use, and number of thromboembolic complications were used to assess effectiveness. In patients receiving warfarin, the combination group had the greatest decrease in INR as well as lowest overall INR, but experienced a higher number of clotting complications, while the rFVIIa group used the most plasma. Non-warfarin patients in the combination group had the shortest length of stay among survivors, but the rFVIIa group had the lowest mortality. Based on this data, it may be prudent to further study the use of rFVIIa in treating extreme bleeding in the non-warfarin patient, while this study supports other data that 4-factor PCC may be the most prudent for the warfarin patient. Am. J. Hematol. 91:705-708, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Emma DeLoughery
- Westminster College; Salt Lake City Utah
- Division of Hematology/Medical Oncology; Knight Cancer Institute, Oregon Health & Science University; Portland Oregon
| | | | - Thomas G. DeLoughery
- Division of Hematology/Medical Oncology; Knight Cancer Institute, Oregon Health & Science University; Portland Oregon
- Division of Laboratory Medicine; Department of Pathology; Oregon Health & Science University; Portland Oregon
- Division of Hematology/Medical Oncology; Department of Pediatrics; Oregon Health & Science University; Portland Oregon
| |
Collapse
|
6
|
Schlunk F, Pfeilschifter W, Yigitkanli K, Lo EH, Foerch C. Treatment with FTY720 has no beneficial effects on short-term outcome in an experimental model of intracerebral hemorrhage. Exp Transl Stroke Med 2016; 8:1. [PMID: 26893821 PMCID: PMC4758011 DOI: 10.1186/s13231-016-0016-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 02/02/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND No evidence-based therapy is available for patients with acute intracerebral hemorrhage (ICH). In view of the profound inflammatory reaction in the perilesional tissue, we investigated in a well-characterized experimental model whether the administration of the immunomodulator fingolimod (FTY720) is neuroprotective in acute ICH. METHODS ICH was induced by means of a stereotactic intrastriatal injection of collagenase type VII-S. FTY720 (1 mg/kg) was administered intraperitoneally 1 h after ICH induction. Hematoma volume was assessed spectrophotometrically at 24 h after ICH induction. The following endpoints were determined at 24 and 72 h, respectively: mortality rate and neurologic outcomes, edema formation, and MMP-9 activity. RESULTS Twenty-four hour after ICH induction, hematoma volume was not statistically different between groups. No difference was found in mortality and neurologic outcomes at 24 and 72 h between FTY720 treated mice and controls. Edema formation was present in both groups on the ipsilateral side with no statistical difference between groups at both time points. No difference was found in MMP-9 levels after 24 and 72 h between groups. CONCLUSIONS Our results suggest that FTY720 has no beneficial effects in the acute phase of experimental ICH.
Collapse
Affiliation(s)
- Frieder Schlunk
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany ; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Waltraud Pfeilschifter
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Kazim Yigitkanli
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Christian Foerch
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany ; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| |
Collapse
|
7
|
Abstract
Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. Most AF patients have a positive net clinical benefit from OAC, excluding those with AF and no conventional stroke risk factors. Balancing the risks of stroke and bleeding is necessary for optimal use of OAC in clinical practice, and modifiable bleeding risk factors must be addressed. Concerns remain over 'non-changeable' bleeding risk factors such as older age, significant renal or hepatic impairment, prior stroke(s) or prior bleeding event(s) and active malignancies. Such AF patients are often termed 'special' AF populations, due to their 'special' risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients. In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these 'special' AF populations.
Collapse
Affiliation(s)
- Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- School of Medicine, Belgrade University, Belgrade, Serbia; University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, United Kingdom.
| |
Collapse
|
8
|
Schlunk F, Greenberg SM. The Pathophysiology of Intracerebral Hemorrhage Formation and Expansion. Transl Stroke Res 2015; 6:257-63. [DOI: 10.1007/s12975-015-0410-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
|
9
|
Schlunk F, Schulz E, Lauer A, Yigitkanli K, Pfeilschifter W, Steinmetz H, Lo EH, Foerch C. Warfarin pretreatment reduces cell death and MMP-9 activity in experimental intracerebral hemorrhage. Transl Stroke Res 2015; 6:133-9. [PMID: 25424451 DOI: 10.1007/s12975-014-0377-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 12/16/2022]
Abstract
Little is known about the pathophysiology of oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH). We compared hematoma volume, number of terminal deoxynucleotidyl dUTP nick-end labeling (TUNEL)-positive cells (indicating cell death), MMP-9 levels, and perilesional edema formation between warfarin-treated mice and controls. Intracerebral hemorrhage was induced by an injection of collagenase into the right striatum. Twenty-four hours later, hematoma volume was measured using a photometric hemoglobin assay. Cell death was quantified using TUNEL staining. MMP-9 levels were determined by zymography, and edema formation was assessed via the wet-dry method. Warfarin increased hematoma volume by 2.6-fold. The absolute number of TUNEL-positive cells in the perihematomal zone was lower in warfarin-treated animals (300.5 ± 39.8 cells/mm2) than in controls (430.5 ± 38.9 cells/mm2; p = 0.034), despite the larger bleeding volume. MMP-9 levels were reduced in anticoagulated mice as compared to controls (p = 0.018). Perilesional edema formation was absent in warfarin mice and modestly present in controls. Our results suggest differences in the pathophysiology of OAC-ICH compared to intracerebral hemorrhage occurring under normal coagulation. A likely explanation is that thrombin, a strong inductor of apoptotic cell death and blood-brain barrier disruption, is produced to a lesser extent in OAC-ICH. In humans, however, we assume that the detrimental effects of a larger hematoma volume in OAC-ICH by far outweigh potential protective effects of thrombin deficiency.
Collapse
|
10
|
Eltringham-Smith LJ, Lei X, Reheman A, Lambourne MD, Pryzdial EL, Ni H, Sheffield WP. The fibrinogen but not the Factor VIII content of transfused plasma determines its effectiveness at reducing bleeding in coagulopathic mice. Transfusion 2014; 55:1040-50. [DOI: 10.1111/trf.12931] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/23/2014] [Accepted: 09/26/2014] [Indexed: 01/19/2023]
Affiliation(s)
| | - Xi Lei
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - Adili Reheman
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - Melissa D. Lambourne
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
| | - Edward L. Pryzdial
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Centre for Blood Research; University of British Columbia; Vancouver British Columbia Canada
| | - Heyu Ni
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - William P. Sheffield
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton Ontario Canada
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
| |
Collapse
|
11
|
Yampolsky N, Stofko D, Veznedaroglu E, Liebman K, Binning MJ. Recombinant factor VIIa use in patients presenting with intracranial hemorrhage. Springerplus 2014; 3:471. [PMID: 25197623 PMCID: PMC4155054 DOI: 10.1186/2193-1801-3-471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/18/2014] [Indexed: 12/04/2022]
Abstract
Recombinant factor VIIa (rFVIIa) can be used for rapid INR normalization in life-threatening hemorrhage in anticoagulated patients. Dosing is unclear and may carry thromboembolic risks. We reviewed the use of rFVIIa at a comprehensive stroke and cerebrovascular center to evaluate dose effectiveness on INR reduction and thromboembolic complications experienced. The primary endpoint was to review the efficacy of rFVIIa in lowering INR. Secondary endpoints included doses used and adverse effects caused by rFVIIa administration. Forty-one percent of patients presented with a subdural hemorrhage. The mean INR prior to rFVIIa administration was 3.5 (0.9-15) and decreased to 1.13 (0.6-2). The mean dose of rFVIIa given was 73 mcg/kg (±24 mcg/kg). Two patients (3%) experienced a thromboembolic event. Recombinant factor VIIa appears to lower INR without significant thromboembolic complications.
Collapse
Affiliation(s)
- Natalie Yampolsky
- Department of Pharmacy, Capital Health Regional Medical Center, 750 Brunswick Ave, Trenton, NJ 08534 USA
| | - Douglas Stofko
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Erol Veznedaroglu
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Kenneth Liebman
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Mandy J Binning
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| |
Collapse
|
12
|
Chen S, Zeng L, Hu Z. Progressing haemorrhagic stroke: categories, causes, mechanisms and managements. J Neurol 2014; 261:2061-78. [PMID: 24595959 PMCID: PMC4221651 DOI: 10.1007/s00415-014-7291-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/14/2014] [Accepted: 02/17/2014] [Indexed: 01/19/2023]
Abstract
Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.
Collapse
Affiliation(s)
- Shiyu Chen
- Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | | | | |
Collapse
|
13
|
|
14
|
Won SY, Schlunk F, Dinkel J, Karatas H, Leung W, Hayakawa K, Lauer A, Steinmetz H, Lo EH, Foerch C, Gupta R. Imaging of contrast medium extravasation in anticoagulation-associated intracerebral hemorrhage with dual-energy computed tomography. Stroke 2013; 44:2883-90. [PMID: 23920016 DOI: 10.1161/strokeaha.113.001224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Contrast medium extravasation (CE) in intracerebral hemorrhage (ICH) is a marker of ongoing bleeding and a predictor of hematoma expansion. The aims of the study were to establish an ICH model in which CE can be quantified, characterized in ICH during warfarin and dabigatran anticoagulation, and to evaluate effects of prothrombin complex concentrates on CE in warfarin-associated ICH. METHODS CD1-mice were pretreated orally with warfarin, dabigatran, or vehicle. Prothrombin complex concentrates were administered in a subgroup of warfarin-treated mice. ICH was induced by stereotactic injection of collagenase VIIs into the right striatum. Contrast agent (350 μL Isovue 370 mg/mL) was injected intravenously after ICH induction (2-3.5 hours). Thirty minutes later, mice were euthanized, and CE was measured by quantifying the iodine content in the hematoma using dual-energy computed tomography. RESULTS The optimal time point for contrast injection was found to be 3 hours after ICH induction, allowing detection of both an increase and a decrease of CE using dual-energy computed tomography. CE was higher in the warfarin group compared with the controls (P=0.002). There was no significant difference in CE between dabigatran-treated mice and controls. CE was higher in the sham-treated warfarin group than in the prothrombin complex concentrates-treated warfarin group (P<0.001). CONCLUSIONS Dual-energy computed tomography allows quantifying CE, as a marker of ongoing bleeding, in a model of anticoagulation-associated ICH. Dabigatran induces less CE in ICH than warfarin and consequently reduces risks of hematoma expansion. This constitutes a potential safety advantage of dabigatran over warfarin. Nevertheless, in case of warfarin anticoagulation, prothrombin complex concentrates reduce this side effect.
Collapse
Affiliation(s)
- Sae-Yeon Won
- From the Department of Neurology, Goethe-University, Frankfurt am Main, Germany (S.-Y.W., F.S., A.L., H.S., C.F.); Neuroprotection Research Laboratory, Massachusetts General Hospital, Charlestown (S.-Y.W., F.S., H.K., W.L., K.H., E.L.); and Department of Radiology, Massachusetts General Hospital, Boston (J.D., R.G.)
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Frumkin K. Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates. Ann Emerg Med 2013; 62:616-626.e8. [PMID: 23829955 DOI: 10.1016/j.annemergmed.2013.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/23/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.
Collapse
Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center Portsmouth, VA.
| |
Collapse
|
16
|
Abstract
Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.
Collapse
Affiliation(s)
| | - J Javier Provencio
- Neurointensive Care Unit, Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA Neuroinflammation Research Center, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
17
|
Lauer A, Pfeilschifter W, Schaffer CB, Lo EH, Foerch C. Intracerebral haemorrhage associated with antithrombotic treatment: translational insights from experimental studies. Lancet Neurol. 2013;12:394-405. [PMID: 23518332 DOI: 10.1016/s1474-4422(13)70049-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Little is known about the pathophysiology of intracerebral haemorrhage that occurs during anticoagulant treatment. In observational studies, investigators have reported larger haematoma volumes and worse functional outcome in these patients than in those with intracerebral haemorrhage and a normal coagulation status. The need to prevent extensive haematoma enlargement by rapid reversal of the anticoagulation seems intuitive, although no evidence is available from randomised clinical trials. New oral anticoagulants, such as the direct thrombin inhibitor dabigatran and the factor Xa inhibitor rivaroxaban, have been approved recently; however, intracerebral haemorrhage during dabigatran or rivaroxaban anticoagulation has not been characterised, and whether anticoagulation reversal can be beneficial in this scenario is unknown. In a translational approach, new experimental models have been developed to study anticoagulation-associated intracerebral haemorrhage in more detail and to test treatment strategies. Vitamin k antagonists enlarge haematoma volumes and worsen functional outcome in animal models. Rapid reversal of anticoagulation in the experimental setting prevents prolonged haematoma expansion and improves outcome. The new oral anticoagulants increase intracerbral haemorrhage volumes less than does warfarin. Haemostatic approaches that have been used for vitamin k-associated intracerebral haemorrhage also seem to be effective in intracerebral haemorrhage associated with the new anticoagulants. These experimental studies are valuable for filling gaps in knowledge, but the results need careful translation into routine clinical practice.
Collapse
|
18
|
Woo CH, Patel N, Conell C, Rao VA, Faigeles BS, Patel MC, Pombra J, Akins PT, Axelrod YK, Ge IY, Sheridan WF, Flint AC. Rapid Warfarin reversal in the setting of intracranial hemorrhage: a comparison of plasma, recombinant activated factor VII, and prothrombin complex concentrate. World Neurosurg 2012; 81:110-5. [PMID: 23220122 DOI: 10.1016/j.wneu.2012.12.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 06/04/2012] [Accepted: 12/03/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the safety and effectiveness of three methods of reversing coagulopathic effects of warfarin in patients with potentially life-threatening intracranial hemorrhage. METHODS A retrospective electronic medical record review of 63 patients with warfarin-related intracranial hemorrhage between 2007 and 2010 in an integrated health care delivery system was conducted. The three methods of rapid warfarin reversal were fresh-frozen plasma (FFP), activated factor VII (FVIIa; NovoSevenRT [Novo Nordisk, Bagsværd, Denmark]), and prothrombin complex concentrate (PCC; BebulinVH [Baxter, Westlake Village, California, USA], ProfilnineSD [Grifols, North Carolina, USA]), each used adjunctively with vitamin K (Vit K, phytonadione). We determined times from reversal agent order to laboratory evidence of warfarin reversal (international normalized ratio [INR]) in the first 48 hours and compared INR rebound rates and complications in the first 48 hours. RESULTS Reversal with FFP took more than twice as long compared with FVIIa or PCC. To reach an INR of 1.3, mean (±SD) reversal times were 1933 ± 905 minutes for FFP, 784 ± 926 minutes for FVIIa, and 980 ± 1021 minutes for PCC (P < 0.001; P < 0.01 between FFP and FVIIa, P < 0.05 between FFP and PCC). INR rebound occurred in 0 of 31 patients for FFP, 4 of 8 for FVIIa, and 0 of 7 for PCC (P = 0.001). Complications were uncommon. FVIIa was 15 and 3.5 times as expensive as FFP and PCC, respectively. CONCLUSION As an adjunct to Vit K for rapid warfarin reversal, FVIIa and PCC appear more effective than FFP. Either FVIIa or PCC are reasonable options for reversal, but FVIIa is considerably more expensive and may have greater risk of INR rebound.
Collapse
Affiliation(s)
- Carolyn H Woo
- Department of Pharmacy, Kaiser Permanente Medical Center, San Francisco, California, USA.
| | - Nihar Patel
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Carol Conell
- Division of Research, Kaiser Permanente Medical Center, Oakland, California, USA
| | - Vivek A Rao
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Bonnie S Faigeles
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Minal C Patel
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Jasmeen Pombra
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Paul T Akins
- Department of Neurosurgery, Kaiser Permanente Medical Center, Sacramento, California, USA
| | - Yekaterina K Axelrod
- Department of Neurosurgery, Kaiser Permanente Medical Center, Sacramento, California, USA
| | - Ivy Y Ge
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - William F Sheridan
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| | - Alexander C Flint
- Department of Neurosurgery/Neuroscience, Kaiser Permanente Medical Center, Redwood City, California, USA
| |
Collapse
|
19
|
Abstract
Unfractionated heparin, low molecular weight heparin, and warfarin are often used for patients at high risk of thromboembolism and are associated with increased risk of major and even life threatening hemorrhages. They are in use for a long time and have treatment strategies in place in an event of life threatening intracranial hemorrhage. The advent of newer anticoagulants, direct thrombin inhibitors (dabigatran) and two factor Xa inhibitors (rivaroxaban and apixaban), has increased the options of anticoagulation for patients with atrial fibrillation and venous thrombosis, but at the same time, in the absence of an antidote, they have created a great challenge for treating physicians to manage intracranial bleeding related to these agents. In this paper, we will briefly summarize the state of knowledge regarding the risk of anticoagulation-related ICH, and review basic concepts on anticoagulation reversal and the general management of patients with this complication.
Collapse
|
20
|
Lambourne MD, Eltringham-Smith LJ, Gataiance S, Arnold DM, Crowther MA, Sheffield WP. Prothrombin complex concentrates reduce blood loss in murine coagulopathy induced by warfarin, but not in that induced by dabigatran etexilate. J Thromb Haemost 2012; 10:1830-40. [PMID: 22817470 DOI: 10.1111/j.1538-7836.2012.04863.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Both established oral anticoagulants such as warfarin and newer agents such as dabigatran etexilate (DE) effectively prevent thromboembolic disease, but may provoke bleeding. Limited clinical data exist linking oral anticoagulant reversal and bleeding tendency, as opposed to surrogate laboratory markers. OBJECTIVE To quantify bleeding in warfarin-anticoagulated and DE-anticoagulated mice by tail transection with or without pretreatment with potential reversal agents: prothrombin complex concentrate (PCC); activated PCC (APCC); recombinant factor VIIa (rFVIIa); or murine fresh-frozen plasma (FFP). METHODS CD1 mice were given warfarin or DE by gavage, and the effects on in vitro coagulation assays, volume of blood loss and the bleeding time following tail transection injury were evaluated with different reversal agents. RESULTS PCC (14.3 IU kg(-1) ), but not rFVIIa (3 mg kg(-1) ) or FFP (12 mL kg(-1) ), normalized blood loss and bleeding time in mice with warfarin-induced elevations of mean prothrombin time at two intensities (prothrombin time ratios of either 4.3 or 24). Neither separate nor combined PCC and/or rFVIIa treatment nor APCC (100 U kg(-1) ) treatment significantly reduced blood loss in mice anticoagulated with 60 mg kg(-1) DE 75 min prior to tail transection. Both combined PCC plus rFVIIa treatment and APCC treatment significantly reduced bleeding time in the DE-treated mice. CONCLUSIONS Our data suggest that PCC treatment prevents excess bleeding much more effectively in warfarin-induced coagulopathy than in DE-induced coagulopathy.
Collapse
Affiliation(s)
- M D Lambourne
- Canadian Blood Services, Research and Development, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | |
Collapse
|