subdural hematoma a double-edged sword Adam Mah, LMPS resident - - PowerPoint PPT Presentation

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Stroke prophylaxis in an atrial fibrillation patient with chronic subdural hematoma – a double-edged sword

Adam Mah, LMPS resident SPH/LGH Pod October 12th, 2017

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Learning objectives

• Critically appraise the literature for OAC

for patients with history of chronic subdural hematoma and atrial fibrillation (AF)

• Weigh the benefits and risks of OAC in a

patient with non-valvular A-fib and history

• f chronic subdural hematoma
• Compare and contrast anticoagulation

strategies for an inpatient with AF and history of chronic subdural hematoma

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ID

BW, 87 yo female admitted Sept 20th to PIMS, transferred to CTU on Sept 26th

C/C

Back pain

HPI

Slipped and fell while using walker, found down but conscious by son in bathroom

PMHx - TIA (2008) - CAD - Hypothyroidism

• Paroxysmal AF - COPD - Chronic constipation
• Recurrent falls, last 2016 - HTN
• Chronic subdural hematoma (~2008)
• Pacemaker for 2nd degree heart block

FHx

Non-contributory for CV risk and osteoporosis

SHx

Lives in residential care, no smoking, no EtOH, no illicits

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Vitals BP 160/80, HR 70, RR 20 (90% 2L NP), temp not documented  now RR 16 saturating 94%

• n RA

CNS/Psyc AAOx3, GCS 15  delirious last HS, not easily rousable HEENT Pt refused full exam in ED Resp Chest clear to ascultation, no wheezes CV Pt refused full exam in ED. CHADS2 = 4 GI Exam normal GU JVP not observed. No CVA tenderness Endo Not thirsty; A1c 5.6% (Sept 20) Heme No bruising, no hemoptysis or hematemesis MSK 7-9/10 pain to lumbar spine region (L3 to L4) Derm Unremarkable Allergies NKDA

Labs and diagnostics

• Admission (current)

– Na 140 (133), K 4.6 (4.2), SCr 104 (118), eGFR 42 (36), CrCl 30 (27) – INR 2.7 (1.2), albumin 32 (24), lactate 0.8 – NT-pro-BNP 3155, troponin 39, QTc 607 ms – TSH 0.31, A1c 5.6, random BG 6.5

• CT head: chronic subdural hematoma that

is “stable and hasn’t grown”, no acute

• changes. CT spine: compression fracture
• Dx: vertebral fracture secondary to

mechanical fall

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Held home medications Continued home medications

Warfarin 4 mg PO daily Melatonin 3-6 mg PO 2 hrs before HS Amlodipine 2.5 mg PO daily Vitamin D 10 000 units PO weekly on Wednesdays Perindopril 2 mg PO daily L-thyroxine 137 mcg PO daily

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Medications in hospital Sufentanil 12.5-25 mcg SL/SC 30 mins before turns (max 4 doses/day) Ipratropium 0.5 mg nebs QID and q4h PRN Salbutamol 2.5 mg nebs QID and q4h PRN Ca carbonate 1250 mg PO daily with food PEG 17 g PO daily Lactulose 30 mL PO daily Bisacodyl 10 mg PO daily HS Sennosides 8.6-17.2 mg PO HS PRN Hydromorphone 0.25 mg PO BID Acetaminophen 975 mg PO/PR QID ASA 81 mg PO/325 mg PR daily Atorvastatin 80 mg PO daily Captopril 12.5-25 mg SL q30min PRN SBP >220

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DTPs – BW is…

• 1. At risk of recurrent cardiogenic ischemic stroke

secondary to not receiving anticoagulation

• 2. At risk of VTE secondary to not receiving

anticoagulation prophylaxis while in hospital

• 3. At risk of recurrent ischemic stroke secondary

to not receiving antihypertensive therapy

• 4. At risk of barrier to discharge secondary to

receiving nebulized ipratropium

• 5. At risk of barrier to discharge secondary to

receiving nebulized salbutamol

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Goals of therapy

• Minimize risk of cardioembolic stroke
• Minimize expansion of chronic subdural

hematoma

• Avoid neurological sequelae
• Minimize adverse drug reactions

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Where does a subdural hematoma (SDH) occur?

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http://www.primehealthchannel.com/wp-content/uploads/2011/02/Subdural-Hematoma-photos.jpg

Are all ICHs made equal?

• SDH = Usually from head injury, mix of

serous fluid and clotted blood1

• Lobar ICH = Higher risk of re-bleed on

anticoagulants2

• Symptoms = decreasing cognition,

headaches1

• As time progresses, risk of clot goes up

and risk of bleed goes down2

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Guidelines for ICH and resumption of anticoagulation

• AHA/ASA3: After non-lobar ICH, may be

considered if “strong indication” – Avoid anticoagulants for >4 weeks

• Canada4: Decision whether to restart on “case-

by-case” basis. Evidence unclear regarding timing

• ESO (Europe)5: “In the absence of

RCTs…cannot make firm recommendations…”

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Treatment alternatives

• No anticoagulation
• Antiplatelet: ASA and/or clopidogrel
• Re-initiate warfarin
• Factor Xa inhibitors

– Rivaroxaban – Edoxaban – Apixaban

• Dabigatran

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PICO

P Patients with indication for

anticoagulation but have suffered subdural hematoma

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Anticoagulation or antiplatelet

C Anticoagulation, antiplatelet, or placebo O Mortality, recurrent ICH, recurrent

ischemic stroke, disability, bleed requiring hospitalization

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Search strategy and results

• PubMed, Medline
• [exp Hematoma, Subdural] AND [Stroke or

Atrial Fibrillation or Warfarin] AND [Anticoagulation]

• Clinical trials, cohort studies, observational

studies

• 2 prospective observational, 1 single-arm

prospective trial

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De Vleeschouwer et al.6

Design

Single-centre prospective observational study

Patient population N = 108

Patients admitted Jun 1993-Dec 2000 with ICH

• 28 had subdural hematoma (SDH), 56 had non-

valvular A-fib (most common OAC indication)

• Median INR upon admission = 3.7

Outcomes

If OACs were restarted, occurrence of thromboembolic event (TE: stroke or VTE), recurrent ICH

Results (n = 25 for restarting OAC)

• Median time to restarting OACs = 11 days
• 0/25 pts who restarted had TE
• 8/81 pts who did not restart had TE.
• 3 dead, 5 severely disabled.
• No SDH in non-restarters
• Of those with SDH who experienced recurrent

SDH while on OAC, 3 out of 4 made a good recovery

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De Vleeschouwer et al.6

Conclusions More prospective research needed for late management Criticisms

• Enoxaparin started in all for

inpatient VTE prophylaxis

• Confounding by indication:

majority had prosthetic valves

• Heterogeneous population

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Claassen et al.7

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Design Single-centre prospective observational study Patient population N = 48

• Patients admitted Nov 2001-Dec 2005 for warfarin-

associated ICH (WAICH)

• Most ICHs were lobar in nature
• Avg age 70.8 in restarted arm, most had comorbid A-fib

and HTN.

• Counted as “restarted” if <60 days from ICH.

Outcomes Mean follow-up = 43 months. Recurrent non-traumatic WAICH, traumatic ICH, extracrainal hemorrhage, thromboembolic stroke, PE, distal arterial embolus. Results (n = 23 for restarting OAC) OAC no OAC

• Thromboembolic stroke: 0/23 vs. 3/25
• VTE: 0/23 vs. 2/25
• Traumatic ICH: 2/23 vs. 0/25
• GI hemorrhage: 2/23 vs. 2/25

Claassen et al.7

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Conclusions WAICH uncommon with resumption.

Defer to clinical judgement. Lobar ICH: not resuming warfarin may result in VTE, but risk of traumatic ICH not zero.

Criticisms

• No documentation whether pts

were on antiplatelets

• Did not mention if VTE prophylaxis

was utilized

• Did not reach statistical

significance

• Only patients where warfarin was

suspected cause for ICH

Yeon et al.8

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Design Prospective single-arm, single-centre trial Patient population N = 20

• Patients admitted Feb 2008-Apr 2010 for burr hole

drainage

• Had warfarin +/- antiplatelets, chronic or acute SDH,

and an INR of >1.5 upon presentation .

• Warfarin restarted 3 days after
• Mean CHADS2 = 2.1; mean INR = 2.64

Outcomes Regular INR monitoring and brain CT scans Results

• Recurrent SDH documented by CT head within a

month of surgery = 3/20

• Any other ICH = 0/20
• Extracrainal hemorrhage within 6 mos = 0/20
• Ischemic stroke/TIA/VTE within 6 mos = 0/20

Yeon et al.8

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Conclusions Restarting warfarin therapy can be done 3 days post-op for SDH. Begs a comparative trial for warfarin resumption post-burr hole drainage Criticisms

• Target INR in study was 1.7-2.5
• CHADS2 only validated in A-fib

patients = 25% pts in trial

• No comparator group and only

included surgery pts

Summary of evidence

Study Days to restart OAC from ICH Strokes and VTE Recurrent ICH De Vleeschouwer et al (2005) Median 11 ↓* ↑*, but ↓ disability Claassen et al (2008) <60 ↓* ↑* Yeon et al (2012) 3 0/20 3/20

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Recommendation/rationale

• Recommend D/C ASA PO and supps
• Recommend start warfarin 4 mg PO daily, INR

target 2-2.5, INR to be taken day 3 after initiation

• Recommend start dalteparin 5000 units SC BID

for at least 5 days, D/C when INR is 2-2.5

• Warfarin toxicity reversible
• Only case reports exist for NOACs

– ARISTOTLE9 cannot be applied – subgroup analysis NNT 434 for ↓ICH, 1.5% of pts had CrCl <30 mL/min

• CrCl >20 mL/min, no need for heparin

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Monitoring plan

Parameter Change When

INR ↑ to 2-2.5 3 days Heart rate Keep at 60-110 bpm Ongoing daily Arrhythmias Subjective sensation of palpitations, room spinning Ongoing daily Blood pressure Decrease to <150/90 mm Hg Ongoing daily ICH Presence of FAST symptoms, headache or cognitive changes from baseline Twice daily Cardiogenic ischemic stroke Presence of FAST symptoms Twice daily Bleeding from gums, rectum Presence of bleeding gums, BRBPR, coffee ground stools/emesis Ongoing daily VTE Hemoptysis, SOB, unilateral leg swelling/tenderness Ongoing daily

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Actual course in hospital

• Recommendation not accepted
• CNS: Suffered left MCA ischemic stroke in

hospital, did not receive alteplase

– Neuro opinion = wait 2 weeks  f/u CT to rule

• ut hemorrhagic transformation then start

apixaban for cardiogenic stroke prophylaxis

• Psyc: Had delirium/agitation: loxapine

1.25 mg PO/SC q4h PRN added – good effect  currently conversing normally

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Actual course in hospital

• MSK: Pain well controlled (does not

require regular hydromorphone anymore)

• GI: Baseline bowel function from

residential care unknown; bowels regular in hospital on regular PEG and lactulose

• Dispo: Transferred back to PIMS

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Resolution of other DTPs

• Recommend re-initiating amlodipine 2.5 mg PO

daily – implemented

• Recommend D/C ipratropium and salbutamol

nebs – implemented

• Recommend ipratropium 40 mcg (2 puffs)

inhaled QID regular via aerochamber - implemented

• Recommend salbutamol 200 mcg (2 puffs)

inhaled q1h PRN SOB via aerochamber - implemented

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References

1. Sahyouni R, Goshtasbi K, Mahmoodi A et al. Chronic Subdural Hematoma: a Historical and Clinical Perspective. World Neurosurg 2017;S1878-8750(17):31571-1. 2. Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med 2010;77(11):791-99. 3. Hemphill JC, Greenberg SM, Anderson CS et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke 2015;46(7):2032-60. 4. Casaubon LK, Boulanger JM, Blacquiere D et al. Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015. Int J Stroke 2015;10(6):924-40. 5. Steiner T, Salman RA, Beer R et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014;9(7):840-55. 6. De Vleeschouwer S, van Calenbergh F, van Loon J et al. Risk Analysis of Thrombo-embolic and Recurrent Bleeding Events in the Management of Intracranial Haemorrhage Due to Oral

• Anticoagulation. Acta Chirugica Belgica 2005;105(3):268-74.

7. Claassen DO, Kazemi N, Zubkov AY et al. Restarting Anticoagulation Therapy After Warfarin- Associated Intracerebral Hemorrhage. Arch Neurol 2008;65(10):1313-18. 8. Yeon JY, Kong DS, Hong SC et al. Safety of Early Warfarin Resumption following Burr Hole Drainage for Warfarin-Associated Subacute or Chronic Subdural Hemorrhage. Journal of Neurotrauma 2012;29:1334-1341. 9. Granger CB, Alexander JH, McMurray JJV et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. NEJM 2011;365(11):981-92. 28

Questions?

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Appendix – patient characteristics

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De Vleeschouwer et al.6

• n = 73 for intraparenchymatous hematoma

(thalamic, cerebelllar, basal ganglionic)

• n = 28 for subdural hematoma
• n = 6 for intraventricular bleed
• n = 1 for subarachnoid hemorrhage
• 77/108 had supratherapeutic INR (≥3)

upon admission

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Claasen et al.7

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Yeon et al.8

• Avg age = 65.1
• Indications for warfarin

– Afib = 15 (10 of which had mechanical valves) – Mitral stenosis = 1 – Femoral vascular graft = 1 – Cerebellar infarction = 1

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