Hemorrhagic stroke management
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Hemorrhagic stroke Microchapters |
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Diagnosis |
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Treatment |
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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015) |
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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012) |
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AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014) |
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AHA/ASA Guideline Recommendations for Prevention of Stroke in Women (2014) Sex-Specific Risk Factors
Risk Factors Commoner in Women |
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Case Studies |
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Hemorrhagic stroke management On the Web |
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American Roentgen Ray Society Images of Hemorrhagic stroke management |
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Risk calculators and risk factors for Hemorrhagic stroke management |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical therapy
Anticoagulants and antithrombotics, key in treating ischemic stroke, can make bleeding worse and cannot be used in intracerebral hemorrhage. Patients are monitored and their blood pressure, blood sugar, and oxygenation are kept at optimum levels.
Coagulation factor deficiency or platelet disorder treatments
Patients with a known coagulation factor deficiency or platelet disorder:[1][2]
- Replacement of the appropriate factor or platelets
- Hematology consult
patient undergoing an IV heparin infusion
- Protamine sulfate IV injection at a dose of 1 mg per 100 U of heparin (maximum dose 50 mg) with adjustment based on time elapsed since discontinuation of heparin infusion
Patients who are receiving low-molecular-weight heparin (reversal may be incomplete)
- Protamine sulfate IV injection at a dose of 1 mg per 100 U of heparin (maximum dose 50 mg)
Vitamin K antagonists (VKAs)
Rapid correction of the international normalized ratio (INR) is recommended.
- Fresh frozen plasma (FFP), along with vitamin K (5 to 10 mg, usually given slowly via the IV route) has been the mainstay of treatment
Recently new treatments have emerged as potential therapies such as:[3][4]
- Prothrombin complex concentrates (PCCs) contains factors II, IX, X, and VII. PCC does not require cross matching, can be reconstituted and administered rapidly in a small volume (20–40 mL) and Several studies have shown that PCCs rapidly normalize the INR (within minutes) in patients taking VKAs.
- Activated PCC FEIBA (factor VIII inhibitor bypassing activity)
- Recombinant activated factor VIIa (rFVIIa)
New Anticoagulant Medication–Related ICH
There are no randomized trials of reversing agents for newer anticoagulants among patients with ICH or other major bleeding complications. Currently available agents in the United States (dabigatran, rivaroxaban, and apixaban) have relatively short half-lives ranging from 5 to 15 hours. Evaluation of the activated partial thromboplastin time and prothrombin time and consultation with a hematologist are reasonable to individualize care. Potential reversal strategies using FEIBA, other PCCs, or rFVIIa might be considered.
- FFP is of unclear utility, and vitamin K is not useful
- FEIBA or rFVIIa may be better for the direct thrombin inhibitor (dabigatran)
- PCCs may be better for the factor Xa inhibitors (rivaroxaban and apixaban)[5][6]
- Activated charcoal can be used if the most recent dose of dabigatran, apixaban, or rivaroxaban was taken within the previous couple of hours[7]
- Hemodialysis has been noted as an option for dabigatran, but less so for rivaroxaban or apixaban[8]
Antiplatelet Medication–Related ICH
References
- ↑ Schulman S, Bijsterveld NR. Anticoagulants and their reversal. Transfus Med Rev. 2007;21:37–48. doi: 10.1016/j.tmrv.2006.08.002.
- ↑ Andrews CM, Jauch EC, Hemphill JC 3rd, Smith WS, Weingart SD. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care. 2012;17(suppl 1):S37–S46. doi: 10.1007/s12028-012-9757-2.
- ↑ Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S–e184S. doi: 10.1378/ chest.11-2295.
- ↑ Hanley JP. Warfarin reversal. J Clin Pathol. 2004;57:1132–1139. doi: 10.1136/jcp.2003.008904.
- ↑ Dager WE, Gosselin RC, Roberts AJ. Reversing dabigatran in life-threat- ening bleeding occurring during cardiac ablation with factor eight inhibi- tor bypassing activity. Crit Care Med. 2013;41:e42–e46. doi: 10.1097/ CCM.0b013e31827caaa3.
- ↑ Oh JJ, Akers WS, Lewis D, Ramaiah C, Flynn JD. Recombinant factor VIIa for refractory bleeding after cardiac surgery secondary to antico- agulation with the direct thrombin inhibitor lepirudin. Pharmacotherapy. 2006;26:569–577. doi: 10.1592/phco.26.4.576.
- ↑ Kaatz S, Kouides PA, Garcia DA, Spyropolous AC, Crowther M, Douketis JD, Chan AK, James A, Moll S, Ortel TL, Van Cott EM, Ansell J. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol. 2012;87 Suppl 1:S141–S145. doi: 10.1002/ ajh.23202.
- ↑ Veshchev I, Elran H, Salame K. Recombinant coagulation factor VIIa for rapid preoperative correction of warfarin-related coagulopathy in patients with acute subdural hematoma. Med Sci Monit. 2002;8:CS98–CS100.