American Heart Association

Monthly Archives: June 2017

Resuming Anticoagulation After Intracranial Hemorrhage: The Tides are Shifting

Danny R. Rose, Jr., MD

Murthy SB, Gupta A, Merkler AE, Navi BB, Mandava P, Iadecola C, et al. Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis. Stroke. 2017

For most clinicians, intracerebral hemorrhage (ICH) is the most feared potential complication of anticoagulation therapy, carrying significant morbidity and mortality. Clinical decision-making regarding the resumption of anticoagulation for patients for whom it is indicated is complex, as many of these patients have significant risk of ischemic and hemorrhagic events. Traditionally, providers have been reluctant to restart anticoagulation after ICH, especially for patients with atrial fibrillation as compared to mechanical valves.

AHA guidelines reflect the lack of clarity on this matter, with current recommendations (Class IIa) to avoid anticoagulation after spontaneous lobar ICH in patients with non-valvular atrial fibrillation (NVAF), and to consider resuming antiplatelet therapy after all ICH and anticoagulation in patients with non-lobar ICH (Class IIb). Selection and timing for resumption of anticoagulation has been the topic of ongoing research, with the results of pertinent studies presented at the International Stroke Conference, as well as the European Stroke Organisation Conference in 2017. In addition to this, a recent meta-analysis published in Stroke by Drs. Murthy et al. sought to address this clinical challenge by reviewing available studies with respect to the safety and efficacy of restarting anticoagulation after ICH. To understand the significance of this study in the context of evolving concepts regarding anticoagulation after ICH, we will start by reviewing a previous study with similar aims.

Key to Identifying the Culprit Aneurysm Among Multiple Aneurysms in Patients with Subarachnoid Hemorrhage

Tapan Mehta, MBBS, MPH

Björkman J, Frösen J, Tähtinen O, Backes D, Huttunen T, Harju J, et al. Irregular Shape Identifies Ruptured Intracranial Aneurysm in Subarachnoid Hemorrhage Patients With Multiple Aneurysms. Stroke. 2017

Endovascular therapy has become the treatment of choice for the majority of ruptured saccular intracranial aneurysms (sIAs). About 15–30% of patients can present with more than one sIA. Identification of ruptured sIA could sometimes be difficult without direct visualization (micro surgically) when more than one sIA is located in close proximity to the site of the hemorrhage on the computed tomography (CT). It is important to identify the ruptured aneurysm correctly to aid definitive endovascular management. This article adds to the literature on the importance of aneurysm shape in addition to size in determining rupture status of sIAs.

Author Interview: Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

Alexandros Rentzos, MD, and Pia Löwhagen Hendén, MD, PhD

A conversation with Alexandros Rentzos, MD, Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, and Pia Löwhagen Hendén, MD, PhD, Anesthesiology and Intensive Care department, Sahlgrenska University Hospital, about the role of anesthesia and conscious sedation for patients undergoing embolectomy for stroke.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke),” published in the June 2017 issue of Stroke.

Dr. Merino: Could you please summarize the key findings of your study and put them in context of what was known on the topic?

Drs. Rentzos and Löwhagen: Since a number of retrospective studies showed that general anesthesia during endovascular stroke treatment was associated with poor neurological outcome, conscious sedation became the main method in most neurointerventional centers after 2010. However, the retrospective studies were limited by important selection bias, such as inclusion of posterior strokes (in some of the series) and, importantly, more severe stroke in patients treated under GA. Furthermore, most retrospective studies on anesthesia technique did not describe the anesthesia technique, nor the anesthetic management!

At our institute, we have used mainly general anesthesia since 1991 when we started with endovascular stroke treatment, and, in our experience, patients treated with GA did not have worse neurological outcome. That is why we started the randomized trial AnStroke in 2013. The results were presented in ESOC 2017 in Prague on May 18. In our trial, general anesthesia did not lead to worse neurological outcome compared to conscious sedation.

Author Interview: Santosh Murthy, MD, MPH

Santosh Murthy

Santosh Murthy

A conversation with Santosh Murthy, MD, MPH, Assistant Professor of Neurology and Neuroscience, Weill Cornell Medicine, about the decision on when to restart anticoagulation after intracranial hemorrhage.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper “Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis,” published in the June 2017 issue of Stroke.

Dr. Merino: Can you please summarize the key findings of your study and place them in context of what was already known on the topic?

Dr. Murthy: There is a lack of standardized recommendations regarding the use of anticoagulant therapy after intracerebral hemorrhage (ICH). Our meta-analysis of observational studies suggests that compared with withholding anticoagulation, resumption of anticoagulant therapy after ICH significantly lowers the risk of ischemic stroke and myocardial infarction (MI) with no discernable elevation in the risk of ICH recurrence. While our results help summarize the existing literature and may serve as a guide to clinicians in making informed decisions, randomized clinical trials are needed to determine the true risk-benefit profile of anticoagulation resumption after ICH.

Calorie-free, But Perhaps Not Risk-free: Artificial Sweeteners and the Risk of Stroke and Dementia

Neal S. Parikh, MD
@NealSParikhMD

Pase MP, Himali JJ, Beiser AS, Aparicio HJ, Satizabal CL, Vasan RS, et al. Sugar- and Artificially Sweetened Beverages and the Risks of Incident Stroke and Dementia: A Prospective Cohort Study. Stroke.

In this entry, I discuss a recent publication by Matthew Pase and colleagues regarding the risks of stroke and dementia associated with the consumption of sugar-sweetened and artificially sweetened beverages.

Citing conflicting data, the authors sought to examine the association of sugar- or artificially sweetened soft drink intake with incident stroke and dementia in the Framingham Heart study.