reversal in brain bleed
- related: Hematology
- tags: #literature #pulmonary
Which of the following statements is true concerning the early management of spontaneous intracerebral hemorrhage (SIH)?
Results from studies in patients presenting with SIH who concurrently are taking vitamin K antagonist anticoagulants such as warfarin have shown benefit from reversal of their anticoagulated state by the administration of 4-factor prothrombin complex as opposed to fresh frozen plasma (choice A is correct).
SIH accounts for 10% to 15% of all strokes. A common problem evolving early after diagnosis is hematoma expansion with consequent neurologic deterioration. This typically occurs within the first 6 h of management. Accordingly, strategies to limit hematoma expansion and thereby improve clinical outcome have been pursued. In the FAST trial, patients were randomly assigned to receive one of two doses of recombinant factor VIIa or placebo within 4 h after the onset of symptoms. Although a reduction in clot size was seen in the group of patients receiving the higher dose of drug at 24 h, this did not translate into improved survival or neurologic outcome (choice C is incorrect). A follow-up trial studying the administration of this agent within a 2-h window has recently been started. The administration of factor VII carries risks of triggering excessive venous and arterial blood clotting.
Because blood pressure (BP) is thought to be a factor influencing hematoma growth, studies have been performed randomly assigning patients to different BP targets. In the ATACH-2 trial, patients were randomly assigned to a systolic pressure target of either 110 to 130 mm Hg or 140 to 180 mm Hg for the first day of management using IV nicardipine as the agent for BP control. No difference in clinical outcome was seen at 90 days (choice D is incorrect). A follow-up trial extending the period of BP management to 7 days also failed to demonstrate a difference between the two strategies. These results may be explained by altered autoregulation of cerebral blood flow after brain injury, a physiologic change that would justify use of higher cerebral perfusion pressures to maintain adequate cerebral perfusion after stroke.
Patients with SIH while taking anticoagulants exhibit a several-fold increased risk of hematoma expansion after initial diagnosis; hence, strategies for aggressive reversal of their anticoagulated state have been evaluated. In the PATCH trial, patients receiving antiplatelet agents were assigned to platelet transfusions or to a control group. The group that received platelet transfusions had twice the mortality and higher rates of neurologic dysfunction (choice B is incorrect).
As a result, American Heart Association guidelines have suggested platelet transfusions should be withheld unless neurosurgical procedures are performed. In studies in patients presenting with SIH who had international normalized ratios greater than 1.9 owing to warfarin use, 4-factor prothrombin complex was shown to correct the international normalized ratio more rapidly, and this treatment reduced the incidence of hematoma expansion (choice A is correct). It is not clear from clinical trial results whether this reduction in hematoma expansion will translate into other benefits such as improved mortality. Nonetheless, guidelines call for the administration of vitamin K and prothrombin complex in this setting.1