Hemorrhage. Dr. Al Jin Nov. 17, 2015

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1 Hemorrhage Dr. Al Jin Nov. 17, 2015

2 None Disclosures

3 ICH Management in ER ABCs Treat hypertension What BP target? Reverse warfarin

4 Hemorrhage vs Ischemic Stroke Lowering BP may be harmful in ischemic stroke and helpful in hemorrhagic stroke Many studies have been done, with most being negative for any benefit

5 ICH Ischemic INTERACT Lancet Neurol 2008 INTERACT 2 NEJM 2013 ATACH Recruitment finished, final results in 2015 ATACH 2 (ongoing) SAMURAI Stroke 2014 COSSACS Lancet Neurol 2010 CHHIPS Lancet Neurol 2009 SCAST Lancet Neurol 2011 CATIS JAMA 2014

6 BP goes up after stroke Many factors at play, including: Neuroendocrine changes (altered levels of norepinephrine, catecholamines, and dysfunction of pituitary-hypothalamicadrenocortical axis) Autonomic dysfunction Disturbed autoregulation Urinary retention, infection, psychological stress

7 How does stroke change BP?

8 Ischemic stroke: N = 523 (40% cardioembolic) Previous HTN: 67% Hemorrhage: N = 113 (58% deep or posterior) Previous HTN: 59% OXVASC, Oxfordshire Community Stroke Project Premorbid BP obtained from primary care records

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11 Small increase in BP with ischemic stroke

12 Large increase in BP with hemorrhagic stroke

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15 Potential harm in BP lowering for ischemic stroke? In patients seen within 90 minutes of stroke onset, the maximum rise in sbp was 5.2 mmhg compared to premorbid levels SCAST showed that acute lowering of BP was associated with a worse outcome in those who had pre-existing hypertension Was this because BP was lowered to levels below that to which the patient had become accustomed? BP didn t increase in the days and weeks leading up to ischemic stroke But it was still high

16 BP lowering in ICH is safer? In patients seen within 90 minutes of stroke onset, the maximum rise in sbp was 50 mmhg compared to premorbid levels Trials such as INTERACT 2 have shown that lowering sbp to 140 mmhg is safe But no benefit shown! (p 0.06) BP increased in the days and weeks leading up to ICH, and increased even further during ICH BP lowered spontaneously within 24 hours

17 Treat sbp to 140 mm Hg?? This can be done safely Although INTERACT-2 trial was negative for benefit (p = 0.06), there is no harm to treat to this target Current Canadian guideline does not specify BP target

18 Surgical intervention? Surgical trials have failed to show benefit for hematoma evacuation Some patients may still be considered anyway Posterior fossa decompression (URGENT) Hematoma is within 1 cm of cortical surface Patient is young and GCS is 9 or higher

19 Coagulopathy For DOACs, there are recent antidotes but availability is an issue Idarucizumab for dabigatran Andexanet alfa for apixaban, rivaroxaban Some evidence that PCC may reverse apixaban? For warfarin, Reverse with PCC to INR 1.2

20 Some questions that were sent to me In the setting of ischemic stroke with hemorrhagic transformation in a patient with atrial fib, when can anticoagulation safely be restarted? Does it depend on the size of the bleed? Anticoagulation is generally held until the hematoma has resolved and is gone or almost gone. Usually takes minimum of 4 weeks, unless either really big or really small.

21 For the newer anticoagulants, if a patient has an infarct while on them, is holding the NOAC for 24h and re scanning for re-bleeding enough? We tend to hold NOAC, scan for hemorrhagic transformation at ~24 to 48 hours. We aren t in a rush to restart NOAC and literature suggests waiting as you would for warfarin. That is, restart no earlier than 3 days post-stroke for tiny infarcts, and maybe wait a week with rescan before restarting NOAC for larger strokes.

22 If patient presents with a NSTEMI and ischemic stroke, what should you do for anticoagulation in the first 24h? Depends on size of infarct. If large infarct, IV heparin carries risk of hemorrhagic transformation and evidence for NSTEMI is weak anyway. We just use antiplatelet agents, but we discuss with Cardiology colleagues. If infarct is tiny, then we are fine with antithrombotic therapy as per usual for NSTEMI.

23 Are there any specific types of strokes that should be referred to KGH, eg brain stem strokes? Strokes to discuss with the KGH neurologist on call: patient under 65 years old with malignant MCA infarct (may need hemicraniectomy), posterior fossa infarcts which may require decompression, large ICH which may require surgery. Brainstem strokes should be within the competence of any stroke unit.