Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

Ganti, Latha; Jain, Anunaya; Bellolio, M. Fernanda; Odufuye, A.O.; Dhillon, R.K.; Manivannan, Veena; Gilmore, R.M.; Rabinstein, Alejandro A.; Chandra, Ramesh; Serrano, Luis A.; Yerragondu, N.; Palamari, B.; Decker, Wyatt W.

doi:10.1016/j.clineuro.2009.12.002

Cited by 38 publications

(34 citation statements)

References 40 publications

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“…The use of antithrombotic agents leading to subsequent impairment of the hemostatic system in patients suffering from TBI, pICH and pSAH is known to be one of the most relevant risk factors for early neurological deterioration, hematoma growth, need for neurosurgical intervention, unfavorable neurological outcome and increased mortality [11,12,15,17,19,25]. Although in univariable analysis a pathological Multiplate result was associated with unfavorable outcome, this association did not persist when multivariable analysis was performed.…”

Section: Discussioncontrasting

confidence: 47%

“…In patients suffering from TBI or ICH, the use of antithrombotic agents as well as subsequent impairment of the hemostatic system is known to be one of the most relevant risk factors for early neurological deterioration, unfavorable neurological outcome and increased mortality [11,12,15,25]. However, in particular patients suffering from acute brain injury are often found with a reduced level of consciousness.…”

Section: Introductionmentioning

confidence: 98%

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High prevalence of pharmacologically induced platelet dysfunction in the acute setting of brain injury

et al. 2015

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Section: Discussioncontrasting

confidence: 47%

Section: Introductionmentioning

confidence: 98%

High prevalence of pharmacologically induced platelet dysfunction in the acute setting of brain injury

et al. 2015

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“…Previously, Senft et al 25 and Taussky et al 30 analyzed a small cohort of patients with aSDH that occurred during OAT (11 and 16 patients) and showed no significant difference in functional outcome or mortality rate. In contrast, several previous studies observing anticoagulation in intracranial hemorrhage reported anticoagulation or antiplatelet treatment at the time of presentation as an important poor prognostic marker, 10,21,24,27,31 and one of the studies 20 reported a 1.7 times higher risk of mortality in patients on OAT at the time of the intracranial hemorrhage. In our study with a larger cohort of patients on OAT (n = 74), we observed similar results, with a clear significance toward unfavorable outcome and a mortality rate in the OAT group that was almost twice as high as that in the no-OAT group.…”

Section: Discussionmentioning

confidence: 74%

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Won

Dubinski

Bruder

et al. 2017

Neurosurgical Focus

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OBJECTIVEIsolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT—with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants—is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation.METHODSIn this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified.RESULTSOf 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1–2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R2 = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R2 = 0.466). OAT itself was not an independent predictor for worse outcome.CONCLUSIONSAn OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.

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“…We prespecified these variables on the basis of their clinical relevance, known or hypothesized influences on outcome, 8,66 and the number of outcome events per variable because 5 to 9 outcome events per variable is valid, especially if variables are selected a priori and the associations found are plausible in the context of current knowledge. 67 We checked the calibration of the model using a likelihood ratio and Hosmer and Lemeshow's goodness of fit test, which divides subjects into deciles based on predicted probabilities of case fatality and calculates χ 2 statistics based on observed and expected frequencies of deaths in each decile (P>0.05 indicates that there is no significant difference between the observed and model-predicted values, implying that the model fits the data adequately).…”

Section: Discussionmentioning

confidence: 99%

Influence of Intracerebral Hemorrhage Location on Incidence, Characteristics, and Outcome

Samarasekera

Fonville

Lerpiniere

et al. 2015

Stroke

146

106

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Background and Purpose-The characteristics of intracerebral hemorrhage (ICH) may vary by ICH location because of differences in the distribution of underlying cerebral small vessel diseases. Therefore, we investigated the incidence, characteristics, and outcome of lobar and nonlobar ICH. Methods-In a population-based, prospective inception cohort study of ICH, we used multiple overlapping sources of case ascertainment and follow-up to identify and validate ICH diagnoses in 2010 to 2011 in an adult population of 695 335. Results-There were 128 participants with first-ever primary ICH. The overall incidence of lobar ICH was similar to nonlobar ICH (9.

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Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

Cited by 38 publications

References 40 publications

High prevalence of pharmacologically induced platelet dysfunction in the acute setting of brain injury

High prevalence of pharmacologically induced platelet dysfunction in the acute setting of brain injury

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Influence of Intracerebral Hemorrhage Location on Incidence, Characteristics, and Outcome

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