Challenges and controversies in the medical management of primary and antithrombotic-related intracerebral hemorrhage

Abstract

Intracerebral hemorrhage (ICH) represents 10-15% of all cerebrovascular events, and is associated with substantial morbidity and mortality. In contrast to ischemic cerebrovascular disease in which acute therapies have proven beneficial, ICH remains a more elusive condition to treat, and no surgical procedure has proven to be beneficial. Aspects pertinent to medical ICH management include cessation or minimization of hematoma enlargement, prevention of intraventricular extension, and treatment of edema and mass effect. Therapies focusing on these aspects include prothrombotic (hemostatic) agents, antihypertensive strategies, and antiedema therapies. Therapies directed towards the reversal of antithrombosis caused by antiplatelet and anticoagulant agents are frequently based on limited data, allowing for diverse opinions and practice styles. Several newer anticoagulants that act by direct thrombin or factor Xa inhibition have no natural antidote, and are being increasingly used for various prophylactic and therapeutic indications. As such, these new anticoagulants will inevitably pose major challenges in the treatment of patients with ICH. Ongoing issues in the management of patients with ICH include the need for effective treatments that not only limit hematoma expansion but also result in improved clinical outcomes, the identification of patients at greatest risk for continued hemorrhage who may most benefit from treatment, and the initiation of therapies during the hyperacute period of most active hemorrhage. Defining hematoma volume increases at various anatomical locations that translate into clinically meaningful outcomes will also aid in directing future trials for this disease. The focus of this review is to underline and discuss the various controversies and challenges involved in the medical management of patients with primary and antithrombotic-related ICH.

Utilization of Clinical Practice Guidelines

“…In the absence of well-designed, randomized, controlled trials, treatment of this patient varies widely. 10,11 Experts agree reversal Utilization of Clinical Practice Guidelines of anticoagulation without delay is necessary to prevent hematoma expansion during the initial 24 to 48 hours. 13 An evaluation tool recommended to identify and prevent process problems is failure mode and effects analysis.…”

“…Although intracerebral hemorrhage represents only 10% to 15% of all cerebrovascular events, it is associated with substantial morbidity and mortality for patients. 11 The incidence of oral anticoagulation-associated intracerebral hemorrhage is growing owing to the increasing use of warfarin, the emergence of multiple new blood thinners, and the older age of treated patients. 12 Optimal treatment is yet to be defined, making this a complex patient to manage.…”

Translating Basic Science Research to Clinical Application: Models and Strategies for Intracerebral Hemorrhage

“…The coagulation of blood along the needle track alleviates the backflow of blood along the needle track and alleviates the need for incorporating heparin, as anticoagulant therapy has been shown to contribute to hematoma expansion (Flibotte et al, 2004 ), mortality (Cucchiara et al, 2008 ), and rebleeding events (Vermeer et al, 2002 ; Matute et al, 2012 ) in ICH patients. However, it should be noted that newer pharmacological agents that are currently under investigation may alleviate adverse outcomes associated with traditional therapies (for review, see Moussouttas, 2012 ).…”