Presentation is loading. Please wait.

Presentation is loading. Please wait.

Girish Hiremath, MD, FAANS.  Spontaneous ICH (sICH)  15% of all acute strokes  Deadliest stroke subtype  1 month mortality of 40%  At 1 year, 75%

Similar presentations


Presentation on theme: "Girish Hiremath, MD, FAANS.  Spontaneous ICH (sICH)  15% of all acute strokes  Deadliest stroke subtype  1 month mortality of 40%  At 1 year, 75%"— Presentation transcript:

1 Girish Hiremath, MD, FAANS

2  Spontaneous ICH (sICH)  15% of all acute strokes  Deadliest stroke subtype  1 month mortality of 40%  At 1 year, 75% die or are severely disabled  Initial hematoma volume remains strongest predictor of 30-day mortality and functional outcome  Only modifiable predictor of outcome Qureshi, Lancet 2009 Van Asch, Lancet Neurol 2010 Broderick, Stroke 1993

3  Larger more likely to expand  Early presentation after symptom onset  Anticoagulation use  Presence of APOE ε 2 allele  CTA spot sign  Newer marker for hematoma expansion  Poor functional outcome, death  Low sensitivity Cucchiara, Stroke 2008 Broderick, Stroke 2007 Delgado, Stroke 2010 Brouwers, Stroke 2012

4  Dilemma: pt with past ICH develops clear indication for A/C such as Afib  Risk of thromboembolism is 4.5% with Afib  Efficacy of warfarin for stroke prevention: 68%  Decision analysis models (no RCT’s)  Assumptions:  Relative risk of bleeding on ASA in this cohort—SDH = 2.0  Relative risk of bleeding on A/C—ICH = 2.0; SDH = 4.0  For 1000 patients with lobar ICH, A/C would result in 31 fewer thromboembolic events, but 150 additional ICH’s  Conclusions:  A/C not indicated after lobar ICH  A/C resumption unclear after deep ICH (probably no unless very high risk of ischemic stroke)  ASA indicated only if RR for deep ICH is < 1.3 and for lobar ICH < 1.04 Eckman, Stroke 2003

5

6  72 year old white man presents with expressive aphasia, headache, declining mental status  Likely spontaneous—no specific hx of trauma  On ASA/PLAVIX for CAD  L Acute SDH (2cm) with 1cm MLS; L inferior frontal contusion/ICH  Underwent platelet tx, emergent craniotomy, evacuation of SDH

7

8 Redo Urgent Craniotomy…

9

10

11

12

13  1 week later:  Admitted to OSH with massive MI, resulting in resumption of ASA/PLAVIX…

14  22071 male physicians (aged 40-84) randomly assigned to 325mg ASA or placebo qOD  At 5 yrs:  ASA use was associated with 2.14 X higher risk of hemorrhagic stroke  Swedish Aspirin Low-dose Trial (SALT)  1360 pts with hx of TIA/minor stroke randomly assigned to 75mg/d of ASA or placebo for 2.8 yrs  ASA use associated with 2.78 X higher risk of hemorrhagic stroke Steering Committee of the Physicians’ Health Study Research Group; NEJM 1989 SALT Collaborative Group; Lancet 1991

15  Meta-analysis of 16 RCT’s on ASA use  International study of 55462 participants  RR reduction of MI with ASA  RR reduction of ischemic stroke with ASA  RR increase in hemorrhagic stroke with ASA (84% increased RR)  (all three were significant at P <.001) He et al, JAMA 1998

16  Meta-analysis of 1880 ICH survivors between 1982 and 2000  Mean age 65  Mean f/u: 3.4 yrs from index ICH  Stroke recurrence:  59% hemorrhagic  26% ischemic  Recurrent ICH occurs at 2X the rate of ischemic stroke in survivors of primary ICH  2.4% per year rate of recurrent ICH  Higher risk with lobar hemorrhage Bailey et al; Neurology 2001

17  207 patients with index ICH  Lobar  Deep  AP prescribed in 22% of survivors  Avg of 5.4 months after index ICH  Most commonly for ischemic cardiovascular dz  ICH recurred in 22% of survivors  No increase in risk of recurrent ICH with ASA resumption  ( p = 0.73)  ICH location not factor (lobar vs. deep)  Limitations:  Selection bias (pts felt to be high risk for repeated ICH likely did not have AP resumption)  Resumption of ASA did NOT significantly improve cardiovasc morbidity ( p =.75)  Small sample size (only 46 pts had recurrent ICH) Viswanathan et al; Neurology 2006 Donnan and Ly; Neurology 2006

18  Observational, Community-based study in Scotland  417 pts with ICH  120 prescribed Antiplatelet medications (28.8%)  Median time from d/c to AP use was 14.8 months  40 ischemic strokes/MI  14 recurrent ICH  Study found no association between AP use and recurrent ICH  Limitations:  Small sample size  Selection bias  ? Delay in resuming of AP to 14.8 months after index ICH Flynn et al; Stroke 2010

19  There is no good answer!  No good literature to guide the neurosurgeon (or neurologist)  There is not likely to be a RCT  In general, it is prudent to wait at least one month  Must be made on a case-by-case basis  NOT by a “protocol-driven” approach

20 VTE is frequent in pts with ischemic and hemorrhagic stroke 5% of early deaths following stroke attributed to PE

21  Incidence of DVT in untreated NS pts: 18-50%  Multiple studies have shown the safety of pharmacological DVT prophylaxis in the setting of elective NS  In 555 pts undergoing elective NS procedures, LDSQUFH:  Reduced DVT by 43% (measured by U/S)  Risk reduction NOT assoc with incr hemorrhage  Did not alter the rate of PE  No correlation between DVT and PE  (In general, 30% of pts with acute PE have no LE DVT)  PE directly related only to length of procedure  (? Lack of statistical power) Khaldi et al; J Neurosurg 2011; Agnelli et al; NEJM 1998; Geerts; Chest 2001 Cage et al; J Neurooncology 2009 Chibbaro Surg Neurol 2008

22  133/151 evaluated at day 10 after ICH  Endpoints: a/symptomatic DVT/PE  14 asymptomatic DVT’s identified  3 in ES only group  11 in ES + IPC group  IPC combined with graded ES reduced the risk of asymptomatic DVT at day 10 following ICH by 71% compared with ES alone. Lacut et al; Neurology 2005 (VICTORIAh study)

23  Meta-analysis of RCT’s of prophylactic use (within 6 days) of SQ  UFH  LMWH  Heparinoids  Endpoints:  A/symptomatic DVT  A/symptomatic PE  Death  A/symptomatic hematoma enlargement Paciaroni et al; J Thrombosis and Haemostasis 2011

24  4 studies included  2 used UFH  2 used LMWH  Results:  A/C resulted in sig reduction in:  PE  A/C resulted in NON-sig  Reduction in mortality  Reduction in DVT  Hematoma enlargement Paciaroni et al; J Thrombosis and Haemostasis 2011

25 97 patients with sICH were all given LMWH in the form of Enoxaparin or Dalteparin 2 patients developed moderate enlargement of hematoma No fatal PE’s Limitations: Non-randomized; no control group; limited sample size Kiphuth et al; Cerebrovasc Dis 2009

26  2 cohorts of 107, 129 pts each with tICH (1 served as a historic control)  Both groups tx with SCD’s  Following stable Head CT, 1 group underwent tx with either LMWH (Lovenox 30mg BID or SQUFH 5000 TID)  Group A (no tx): DVT rate was 5.6%  Group B (tx): DVT rate was 0%  No progression of ICH  NO sig difference in rate of PE ( P = 0.179) with trend towards lower rate of PE in pts undergoing pharmacological prophylaxis Farooqui et al; J Neurosurg 2013

27  In general, rates of DVT and PE are reduced with the use of pharmacological prophylaxis in the setting of sICH and tICH  There is probably no significant hematoma enlargement with the use of such prophylaxis  However, many studies show no significant correlation between DVT and PE; some show no significant reduction in rate of PE with pharm prophylaxis  The idea that mortality is reduced with the use of pharmacological DVT prophylaxis is yet to be proven

28


Download ppt "Girish Hiremath, MD, FAANS.  Spontaneous ICH (sICH)  15% of all acute strokes  Deadliest stroke subtype  1 month mortality of 40%  At 1 year, 75%"

Similar presentations


Ads by Google