Setting Of Intracranial Hemorrhage Research Articles

Acute Loss Of Brain Stem Reflexes Following Intracranial Hemorrhage (P5-7.004)

<h3>Objective:</h3> The objective of this case report is to present a case of acute immune mediate demyelinating polyneuropathy (AIDP) triggered by an intracranial hemorrhage (ICH), which was identified by early loss of brainstem reflexes. <h3>Background:</h3> AIDP is a phagocytic attack on Schwann cells and/or myelin in the peripheral nervous system, resulting in decreased nerve conduction and acute denervation. AIDP has rarely been observed with intracranial hemorrhage or ischemic stroke. Moreover, a diagnosis of fulminant AIDP with a clinical picture of brain death has only been previously described in few case reports, and never in the setting of intracranial hemorrhage. <h3>Design/Methods:</h3> This is a case report, where we describe a patient who underwent ICH evacuation which progressed to fulminant AIDP with loss of brainstem reflexes. <h3>Results:</h3> A 79-year-old female who presented with acute onset left hemiparesis was admitted to the ICU after evacuation of a right frontal-parietal ICH. Two weeks after, the patient’s neurological exam showed an acute loss of corneal, gag and cough reflexes, bilateral mydriasis and flaccid quadriplegia with areflexia. Repeat imaging did not reveal injury that would explain the change in clinical status. A lumbar puncture revealed albumino-cytologic dissociation. Serum studies returned positive for anti-GM1 and TPO antibodies. EMG revealed multiple absent motor and sensory conduction responses and decreased amplitude and conduction velocity. She was treated with intravenous immunoglobulin and plasma exchange therapy. Over the course of one week, she gradually recovered her reflexes, motor strength and became responsive to medical care. <h3>Conclusions:</h3> While the patient’s apparent comatose state and absent brainstem reflexes was suspicious for brain death, the severity of her hemorrhage was not consistent with it. Our diagnosis of fulminant AIDP was based on a combination of neurological examination, lumbar puncture and EMG studies and allowed for effective treatment and recovery of a patient showing signs of apparent brain death. <b>Disclosure:</b> Dr. Malerba has nothing to disclose. Dr. Davitz has nothing to disclose. Dr. Patterson has nothing to disclose. Dr. Nelson has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Spark Healthcare. Dr. Nelson has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer Healthcare. Dr. Nelson has received publishing royalties from a publication relating to health care. Dr. Tsetsou has nothing to disclose.

Comparison of 4-factor prothrombin complex concentrate and andexanet alfa for reversal of apixaban and rivaroxaban in the setting of intracranial hemorrhage.

The purpose of this study was to evaluate and compare clinical outcomes in patients who experienced intracranial hemorrhage (ICH) while taking apixaban or rivaroxaban and were reversed with four-factor prothrombin complex concentrates (4F-PCC) or andexanet alfa (AA). This retrospective cohort included adult patients that received 4F-PCC or AA for the initial management of an apixaban- or rivaroxaban-associated ICH. A primary outcome of excellent or good hemostatic efficacy at 12h post-reversal was assessed. Secondary outcomes evaluated were change in hematoma volume size at 12h, functional status at discharge, need for surgical intervention or additional hemostatic agents post-reversal, new thrombotic event within 28days, 28-day all-cause mortality, discharge disposition, and hospital and intensive care unit lengths of stay. A total of 70 patients were included (4F-PCC, n = 47; AA, n = 23). For the primary outcome analysis, 21 patients were included in the 4F-PCC group and 12 in the AA group. The rate of effective hemostasis was similar between the 4F-PCC and AA groups (66.7% vs 75%, p = 0.62). There were no statistically significant differences between the groups for secondary outcomes, including 28-day mortality (40.4% vs 39.1%, p = 0.92) and thrombotic complications within 28days of reversal (17.0% vs 21.7%, p = 0.63). In patients who experienced an ICH while taking apixaban or rivaroxaban, 4F-PCC and AA were found to have similar rates of excellent or good hemostatic efficacy.

The use of andexanet alfa and 4-factor prothrombin complex concentrate in intracranial hemorrhage

Objectiveto describe the clinical and safety outcomes between andexanet alfa (AA) and 4-factor prothrombin complex concentrate (4F-PCC) for the reversal of apixaban or rivaroxaban in the setting of an intracranial hemorrhage (ICH). MethodsA retrospective, multicentered descriptive study was conducted in hospitalized patients 18 years of age or older from June 2018 to October 2019 who received AA or 4F-PCC for the reversal of apixaban or rivaroxaban in the setting of ICH. Patients were excluded if they had received 4F-PCC prior to AA after its addition to the institution wide formulary. Other exclusion criteria were history or presence of heparin-induced thrombocytopenia or disseminated intravascular coagulation, estimated hematoma volume of >60 mL, Glasgow Coma Scores <7, or no repeat CT head scan. Information was collected from the electronic medical records. The primary outcome was the achievement of excellent or good hemostatic efficacy upon the repeat computer tomography (CT) scan performed after the infusion of study drugs. Secondary outcomes included disposition, survival to hospital discharge, 30-day readmission, length of hospital stay, length of ICU stay, incidence of thromboembolic events. ResultsA total of 24 patients were included in the study, of which 9 received AA and 15 received 4F-PCC. The achievement of excellent or good hemostatic efficacy upon repeat CT scan occurred in 7 (77.8%) patients in the AA group and in 14 (93.3%) patients in the 4-F PCC group. All patients in the AA group survived to hospital discharge with no 30-day morality and 86.7% patients in the 4F-PCC group. ConclusionThis study suggests that real-world clinical and safety outcomes between andexanet alfa and 4F-PCC for the reversal of factor Xa inhibitors in the setting of ICH are similar to ones reported in clinical trials.

Andexanet alfa and four-factor prothrombin complex concentrate for reversal of apixaban and rivaroxaban in patients diagnosed with intracranial hemorrhage.

Limited data exists regarding the clinical outcomes of andexanet alfa and four factor prothrombin complex concentrate (4F-PCC) for reversal of apixaban or rivaroxaban in the setting of intracranial hemorrhage (ICH). The objective of this study was to evaluate clinical outcomes of 4F-PCC and andexanet alfa for reversal of ICH associated with oral factor Xa inhibitors. This was a retrospective, single-center, case series evaluating hemostatic efficacy of patients receiving andexanet alfa) or 4F-PCC for reversal of apixaban or rivaroxaban after ICH. Secondary endpoints included in-hospital mortality, thrombotic complications, timing of reversal agents, intensive care unit and hospital length of stay, patient disposition, and 30-day readmission rate. During the study period, 21 patients received andexanet alfa and 35 received 4F-PCC. Hemostatic efficacy occurred in 64.7% of patients receiving andexanet alfa and 54.8% of receiving 4F-PCC. Thirty-day all-cause mortality was 45.2% for 4F-PCC and 30% for andexanet alfa. Thrombotic events were higher with 4F-PCC (31.4%) compared to andexanet alfa (14.3%). Median time from presentation to administration of reversal agent was 2.67 [1.75-4.13] hours with andexanet alfa and 1.73 [1.21-3.55] hours with 4F-PCC. Discharge to skilled nursing facilities and 30-day readmission were similar between groups. In this cohort, reversal with andexanet alfa and 4F-PCC differed in terms ofhemostatic efficacy and thrombotic events after ICH in patients anticoagulated with apixaban or rivaroxaban.

Corrected white blood cell count, cell index, and validation of a clinical model for the diagnosis of health care-associated ventriculitis and meningitis in adults with intracranial hemorrhage

ObjectivesTo evaluate the utility of the corrected CSF white blood cell (WBC) count, cell index, CSF lactate, CSF glucose and a newly developed diagnostic model for the diagnosis of healthcare-associated ventriculitis or meningitis (HCAVM) in the setting of intracranial hemorrhage (ICH). Patients and methodsA case-control study of 111 adult patients with ICH with HCAVM (cases) or without HCAVM (controls) matched 1:2 by age, Glasgow Coma Scale (GCS), and Acute Physiology and Chronic Health Evaluation II (APACHE II) score enrolled in a large tertiary care center from 2003 to 2016. ResultsSubjects were appropriately matched by age, GCS, and APACHE II score (P > 0.2). Cases had significantly higher CSF WBC count (uncorrected and corrected), cell index, and CSF lactate, but lower CSF glucose levels than controls (P < 0.05). There were no differences between CSF protein, CSF neutrophilic pleocytosis, and serum C-reactive protein between cases and controls (P > 0.1). The diagnostic accuracy as analyzed by the area under the receiver operating characteristic curve (AUC of ROC) was found to be good for the cell index (0.825), fair for the corrected CSF WBC count (0.770), and poor for the diagnostic model and uncorrected CSF WBC count (0.652 and 0.653, respectively). ConclusionThe diagnosis of HCAVM in patients with ICH remains challenging and although no single parameter is sufficient for diagnosis the cell index proved to be an important indicator of infection in our study.

Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants.

Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited. We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included. A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment. These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.

A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures

Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.

Intracranial Hemorrhage in Patients with Durable Mechanical Circulatory Support Devices: Institutional Review and Proposed Treatment Algorithm.

Spontaneous intracranial hemorrhage (ICH) is frequently managed in neurosurgery. Patients with durable mechanical circulatory support devices, including total artificial heart (TAH) and left ventricular assist device (LVAD), are often encountered in the setting of ICH. Although durable mechanical circulatory support devices have improved survival and quality of life for patients with advanced heart failure, ICH is one of the most feared complications following LVAD and TAH implantation. Owing to anticoagulation and clinically relevant acquired coagulopathies, ICH should be treated promptly by neurosurgeons and cardiac critical care providers. We provide an analysis of ICH in patients with mechanical circulatory support and propose a treatment algorithm. We retrospectively reviewed medical records from 2013-2016 for patients with a durable mechanical circulatory device at Banner-University of Arizona Medical Center Tucson. All patients with suspected ICH underwent computed tomography scan of the brain. Anticoagulation was managed by the cardiothoracic surgeon. In 58 patients, an LVAD (n= 49), TAH (n= 10), or both (n= 1) were implanted. Both acquired von Willebrand disease and spontaneous ICH were diagnosed in 5 patients (8.6%) who underwent LVAD implantation. Seven neurosurgical procedures were performed in 2 patients. The overall mortality rate was 60%. Two patients had little or no deficits after treatment with modified Rankin Scale score of 1 and 2, respectively. We propose a novel treatment algorithm to manage patients with a LVAD or TAH and ICH, implemented in a multidisciplinary manner to best avoid neurologic and cardiovascular complications.

Dual-Energy Computed Tomography Angiography of the Head and Neck and Related Applications.

Dual-energy computed tomography (DECT) has become an increasingly widespread and useful component of the neuroimaging armamentarium, offering automated bone removal, metallic artifact reduction, and improved characterization of iodinated contrast enhancement. The application of these techniques to CT neuroangiography enables a number of benefits including more efficient 3D post-processing, contrast dose reduction opportunities, successful differentiation of hemorrhage from contrast staining following thromboembolic recanalization therapy, improved detection of active contrast extravasation in the setting of intracranial hemorrhage, and more precise characterization of atheromatous steno-occlusive disease.

Prothrombin Complex Concentrate for Vitamin K Antagonist-Associated Intracranial Hemorrhage - Global Evidence and the Japanese Perspective.

Patients receiving vitamin K antagonists (VKAs) are at increased risk of bleeding. Intracranial hemorrhage (ICH) is a major cause of morbidity and mortality in this population, and is a particular concern among Japanese clinicians, given reports of an elevated risk of this bleeding type in patients of Asian ethnicity. Patients with VKA-associated ICH require rapid international normalized ratio (INR) reversal, and treatment guidelines suggest the use of prothrombin complex concentrates (PCCs) or plasma for this purpose. Although European and US guidelines recommend PCCs for the treatment of VKA-associated major bleeding, they do not make a specific recommendation in the setting of ICH, owing to the lack of comparative evidence. In contrast, Japanese guidelines recommend the use of PCCs rather than plasma for VKA reversal in patients with ICH; however, these agents are not currently licensed in Japan for this indication. Here we review the available evidence on the use of PCCs for the treatment of VKA-associated ICH, both globally and specifically in Japanese settings. Overall, the evidence reviewed here supports the use of PCC for rapid VKA reversal in these patients.

Developing Guidelines for the Reversal of Anticoagulant and Antithrombotic Agents in the Setting of Intracranial Hemorrhage.

The use of anticoagulants and antithrombotic agents in the population is increasing as the population ages with a concomitant rise in chronic diseases such as atrial fibrillation. The incidence of intracranial hemorrhage (ICH) with these agents is small but clinically significant. The purpose of this article is to illustrate how a single institution developed anticoagulation-associated ICH treatment guidelines. A literature review of the topic was performed using the PubMed and Cochrane Evidence-Based Medicine review databases using keywords including antithrombotic agents, antiplatelet agents, traumatic brain injury, and intracranial hemorrhage. The results of the search were reviewed, and relevant English-language manuscripts were retained. The pharmacology of each agent was reviewed. Anticoagulants increase the risk and severity of ICH; the association is not as clear with the use of antithrombotic agents. Each agent's pharmacology and development is discussed, and reversal strategies are reviewed. Whereas some agents may be reversed medically, others are dialyzable, and a few agents have no effective reversal mechanism currently available. ICH, either primary or traumatic, that is complicated by these agents must be rapidly recognized and appropriately treated. Use of a common, simple clinical practice guideline will assist clinicians in intervening rapidly for this patient group.

Cerebral Venous Thrombosis Associated with Intracranial Hemorrhage and Timing of Anticoagulation after Hemicraniectomy

Cerebral venous thrombosis (CVT) is a rare cerebrovascular event that can present with headache, seizure, and focal neurological deficits. Approximately 30%-40% of patients with CVT also present with intracranial hemorrhage. Current guidelines recommend anticoagulation after CVT even in the setting of intracranial hemorrhage, but the timing of initiation is unclear. We present a case of CVT where timing of anticoagulation was unclear by current guidelines. We conducted a literature search with search terms of "cerebral venous thrombosis," "intracranial hemorrhage," and "anticoagulation." Abstracted information included anticoagulation status and time of initiation of anticoagulation. We present a 30-year-old woman with sudden onset of right hemiplegia, global aphasia, and new-onset seizures diagnosed with left transverse and sigmoid sinus thrombosis with intraparenchymal hemorrhage. The patient was treated with endovascular thrombectomy and decompressive hemicraniectomy due to hemorrhage expansion, and anticoagulation was restarted 8 days after hemicraniectomy. The literature review demonstrated a wide variation of timing for anticoagulation initiation in patients with CVT and intracranial hemorrhage. Most started anticoagulation within 24 hours of admission with similar functional neurological recovery. Current guidelines on the treatment of CVT, even with intracranial hemorrhage, recommend anticoagulation. Most reports in the literature state initiation of anticoagulation within 24 hours. However, the literature does not definitively state when to initiate anticoagulation in a patient with CVT, intracranial hemorrhage, thrombectomy, and decompressive hemicraniectomy. This case illustrates the challenge of determining when to resume anticoagulation for CVT.

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine.

The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes. The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated. Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage. This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism

Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism

Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism.

Venous thromboembolism (VTE) is a complication of glioblastoma. Anticoagulating patients with glioblastoma carries a theoretical risk of intracranial hemorrhage (ICH). We performed a retrospective cohort study of consecutive glioblastoma patients (2007-2013) diagnosed with VTE. The study population comprised of 523 glioblastoma patients of whom 173 (33%) had VTE events. Seventeen (10%) had ICH: 6 (35%) subdural hematomas and 11 (65%) intratumoral hemorrhages. In total, 4 patients with ICH required neurosurgical intervention. Enhancement in the area of subsequent intratumoral hemorrhage was noted in 9 of 10 with available pre-ICH scans. Multivariable regression did not show associations between ICH and tumor enhancement diameter or use of vascular-endothelial-growth-factor inhibitor. Fifteen (16%) patients receiving anticoagulation had ICH compared with 2 (2.6%) not receiving anticoagulation (P = .005). The method of anticoagulation was not associated with development of ICH. Median survival times from nondistal VTE diagnosis to death were 8.0 and 3.5 months (P = .05) in patients receiving anticoagulation and those not on anticoagulation, respectively. Patients with glioblastoma and VTE on anticoagulation have increased incidence of ICH. However, development of ICH was not associated with lower median survival from time of VTE. Intratumoral hemorrhage occurred within the enhancing portion of tumor; however, no relationship was identified between the development of ICH and (i) the median diameter of enhancement or (ii) type of anticoagulant used. However, patients with absence of enhancing tumor did not have intratumoral bleed, suggesting gross total resection may limit this adverse outcome. It is appropriate to initiate anticoagulation in glioblastoma patients with VTEs.

Reversing the effects of antiplatelet agents in the setting of intracranial hemorrhage: a look at the literature.

Patients are increasingly being prescribed antiplatelet agents (APAs) for a growing number of medical and surgical conditions. These agents are associated with an increased risk of hemorrhage, including intracranial hemorrhage (ICH). In the setting of warfarin use and ICH, strategies to reverse the drug effects have improved outcomes. No such strategy exists for APAs, and these patients continue to have poor posthemorrhage outcomes. One strategy is the use of platelet transfusions to provide functional, circulating platelets. Studies have shown mixed results regarding the benefit of this practice. Other strategies include the use of desmopressin and recombinant factor VIIa. More studies are necessary to delineate the effectiveness of the various strategies.

Premorbid Use of Clopidogrel Portends Worse Outcomes in Patients Treated Surgically for Intracranial Hemorrhage

Background: Widespread use of antiplatelet and anticoagulation medications (APACs) can be a difficult challenge in the presence of a neurosurgical emergency. Premorbid use of APACs, particularly clopidogrel, has been shown to affect outcomes in patients with stroke and traumatic brain injury. Objective: We hypothesized that pre-morbid clopidogrel use in patients with intracranial hemorrhage necessitating surgical intervention would lead to a greater risk of death and need for re-operation than those taking other APACs. Methods: Retrospective single institution review was conducted from January, 2010 through November, 2012 for intracranial hemorrhages necessitating surgical evacuation. Acute, subacute and chronic subdural, epidural and intraparenchymal hemorrhages were included. Results: 185 of 410 patients that required surgery for intracranial hemorrhage were on APACs. Overall mortality rate was 33%, with a 37% mortality rate in the APAC group. Overall reoperation rate was 7.5%, and 13% in the APAC group. Chi-square testing demonstrated significance between mortality and clopidogrel use (p = 0.0038), but not in APAC, warfarin or aspirin groups. There was statistical significance between the need for reoperation and APAC use (p = 0.002), aspirin use (p = 0.0097), and clopidogrel use (p = 0.0152), but not warfarin. Multivariate regression demonstrated only clopidogrel use is associated with higher mortality (p = 0.05) and need for reoperation (p = 0.0206). Conclusion: APAC use in the setting of intracranial hemorrhage necessitating surgical evacuation have higher intraoperative blood loss, need for transfusion and risk for adverse cardiac events. Premorbid clopidogrel use is associated with an increased risk in mortality and need for reoperation.

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Introduction: Kcentra, a 4-factor prothrombin complex concentrate (PCC), is indicated for the urgent reversal of acquired coagulation factor deficiency induced by vitamin K antagonist therapy in adult patients with acute major bleeding. Our institution developed an order set correcting iatrogenic coagulopathy in the setting of intracranial hemorrhage (ICH) to ensure appropriate use of this agent. Methods: A retrospective analysis was conducted on patients who received 4-factor PCC from July 5 - August 20, 2013. The following data was collected: patient age, gender, weight, history of thrombosis, PCC indication, anticoagulant-related bleed, PCC dose, use of vitamin K and dose, use of packed red blood cells (PRBC) or fresh frozen plasma (FFP), pre-and post-INR, PT, PTT values, incidence of thrombosis, hypersensitivity reactions, hemostasis, and mortality. Evaluation included patients ≥18 years of age who received 4-factor PCC. Patients were excluded for history of hemophilia, heparin-induced thrombocytopenia, anaphylactic/severe reaction to Kcentra, or if they had disseminated intravascular coagulation. Results: A total of nine patients were included, of which 66% were male with a median age of 77 years and median weight of 84.8 kg. Of the nine patients, two had a history of thrombosis. Fifty five percent of patients had ICH, 22% received Kcentra for reversal of supratherapeutic INR prior to surgical procedure, and 22% had gastrointestinal bleeding. Sixty-six percent of patients had bleeding secondary to warfarin. Only 44% of patients received Kcentra according to the hospital protocol with appropriate dosing according to INR and patient weight. Eighty-nine percent received vitamin K with PCC, and 44% of patients received concomitant PRBC or FFP. Only 11% of patients had a repeat INR rechecked within 30 minutes after PCC. All patients who presented with major bleeding experienced hemostasis post-PCC. No thrombosis or in-hospital mortality was observed. Conclusions: Less than half of patients received 4-factor PCC according to hospital protocol. All patients with major bleeding developed hemostasis post-PCC. No thrombosis was observed. Education efforts will be implemented to increase adherence to the hospital protocol.

Neurologic Complications of Infective Endocarditis

Symptomatic neurologic complications of IE are frequent, and asymptomatic cerebral embolism diagnosed by magnetic resonance imaging (MRI) occurs in many more patients. Neurologic complications increase mortality and complicate surgical decision-making. The most common neurologic complication is stroke due to septic embolism. Other complications include micro- and macro-abscesses, infectious aneurysms, and more general toxic-metabolic encephalopathies, cerebrospinal fluid (CSF) pleocytosis, and seizures. Neurologic complications influence diagnosis, management, and prognosis. MRI should be obtained in all patients with suspected IE and may identify cerebral abnormalities in many IE patients who do not have neurologic symptoms. MRI sequences should include diffusion weighted imaging (DWI) and gradient echo (GRE) to detect ischemic and hemorrhagic infarction. The detection of clinically silent ischemic or hemorrhagic brain lesions may affect performance or timing of surgery, choice of valve prosthesis, and antimicrobial or anticoagulant therapeutic planning. Neurologists should recommend urgent cerebral angiography in the setting of intracranial hemorrhage so that endovascular treatment of mycotic (infectious) aneurysms can be planned. Patients with large vegetations by echocardiography should be considered for surgery before embolism occurs. They should be referred to centers with extensive surgical experience in debridement of infected tissue and infectious disease expertise in antibiotic choice. Additional indications for surgery to replace the affected valve include heart failure, difficult-to-treat pathogens (such as fungi), elevated left ventricular or atrial pressure due to valvular regurgitation, and perivalvular abscess. Patients with cerebral embolism due to IE should not be anticoagulated. Anticoagulation should be stopped as soon as a diagnosis of IE is suspected, particularly if S. aureus infection is likely. Early surgery is recommended for those with transient ischemic attacks and small infarctions. Neurologists can assist the surgical team by providing neurological preoperative clearance for surgical intervention. Contraindications to early valve replacement include coma, large cerebral infarctions and intracranial hemorrhage.

Use of Prothrombin Complex Concentrates and Fibrinogen Concentrates in the Perioperative Setting: A Systematic Review

The use of prothrombin complex concentrates (PCCs) and fibrinogen concentrates (FIBCs) to achieve hemostasis in the perioperative setting as alternatives to allogeneic blood products remains controversial. To examine the efficacy and safety of PCCs and FIBCs, we conducted a systematic review-in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement-to compare the use of these transfusion alternatives in bleeding surgical patients. We performed a literature search of English articles published between July 1997 and July 2012 in MEDLINE via PubMed, The Cochrane Library, and CINAHL. Five randomized trials and 15 nonrandomized studies with a comparator group were included in the final review. Studies were sorted into 1 of the following 3 clinical settings: cardiac surgery, non-cardiac surgery, and reversal of warfarin anticoagulation. Risk of bias was assessed using the Cochrane risk of bias tool. With the exception of 2 randomized controlled trials, the existing body of literature on the use of PCCs and FIBCs in the perioperative setting was assessed to have a high degree of methodological bias. Overall, prospective studies in the cardiac surgery grouping suggested that patients receiving FIBC and/or PCCs required less allogeneic blood transfusion and had less chest tube drainage. In studies of warfarin reversal, PCCs more rapidly corrected the International Normalized Ratio compared to plasma; however, in the setting of intracranial hemorrhage, functional outcomes were poor regardless of the reversal strategy. With regards to safety outcomes, reporting was not uniform and raises concerns of underreporting. Adequately powered, methodologically sound trials would be required for more definitive conclusions to be drawn about the efficacy of PCCs and FIBC over conventional blood components for the treatment of perioperative coagulopathy in bleeding patients.