Faculty Bibliography

BACKGROUND:Little data exists regarding reversal and resumption of antithrombotics following left ventricular assist device (LVAD)-associated intracranial hemorrhage (ICH). METHODS:Prospectively collected data of LVAD patients with ICH was reviewed. Coagulopathy reversal agents, antithrombotic regimens and thrombotic (venous thromboembolism, ischemic stroke, myocardial infarction) and hemorrhagic (recurrent ICH, gastrointestinal bleed, anemia requiring transfusion) complications were recorded. RESULTS:Of 405 patients, intracranial hemorrhage occurred in 39 (10%): 23 intracerebral hemorrhages, 10 subarachnoid hemorrhages, and 6 subdural hematomas. Of 27 patients who received antithrombotic reversal, 8 (30%) had inadequate coagulopathy reversal and 3 of these had hemorrhage expansion or died before repeat imaging. One (4%) had a thrombotic complication (deep vein thrombosis). Antithrombotic therapy was resumed in 17(100%) survivors in a median time 8 days for antiplatelet agents, and 14 days for warfarin. Recurrent intracranial hemorrhage occurred within a median of 7 days of antithrombotic resumption, while ischemic stroke occurred in a median of 428 days. Patients who resumed antiplatelets alone (N=4) had a trend toward more thrombotic events (1.37 vs. 0.14 events-per-patient-year [EPPY],P=0.08), including more fatal thrombotic events (0.34 EPPY vs. 0.08, P=0.89) compared to those resuming warfarin±antiplatelet (N=14). Non-fatal hemorrhage event rates were 0.34 EPPY in the warfarin±antiplatelet vs. 0 EPPY in the antiplatelet alone group (P=0.16). No fatal hemorrhagic events occurred. CONCLUSIONS:Reversal of anticoagulation appears safe following LVAD-associated intracranial hemorrhage, though inadequate reversal was common. Resumption of warfarin±antiplatelet was associated with fewer fatal and non-fatal thrombotic events compared to antiplatelets alone, though more non-fatal hemorrhage events occurred.

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity. METHODS:We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions. RESULTS:Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P < .001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P < .001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046). CONCLUSIONS:Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.

Introduction The 5 seminal mechanical thrombectomy (MT) trials had a median age of 68 years. Though some of these trials included nonagenarians, there is little data on their outcomes. We aimed to compare the procedural, discharge outcomes and complications, of MT for acute ischemic stroke (AIS) in nonagenarians versus younger patients(<=69) Methods Patients with AIS admitted to two comprehensive stroke centers were enrolled prospectively in a registry. Rates of MT were compared between nonagenarians vs <=69. Among those who underwent MT, procedural outcomes, complications, and discharge disposition were compared in propensity scorematched groups (matched for NIHSS, pre-stroke mRS, IV-tPA administration and T IG grade>=2b) of nonagenarians to patients<=69. Good discharge disposition was defined as a discharge to home/acute rehabilitation. Results Of the 3010 AIS patients, 46/297 (16%) nonagenarians underwent MT compared to 159/1337 (12%) patients <=69 (P=0.091) with TICI>=2b of 89% vs 94%; p=0.238 respectively. 78 patients (N=39 >=90, N=39 <69) were propensity score-matched with a median admission NIHSS of 22 and 19, and median ASPECTS of 9 and 9, respectively (both P>0.05). Those <69 more often had Ml occlusions than nonagenarians (84% vs 50%, P=0.035), whereas ICA (10% vs 13%, p=0.76), and M2 (21% vs 43%, p=0.19) occlusions were similar between the two groups. Time to groin puncture (100+/-65 vs 76+/-34; p=0.124), revascularization time (134+/-72 vs 110+/-54; p=0.145), complication rates (0 vs 5.1%; p=0.494) and inhospital deaths (11% vs 24%; p=0.155) were similar among the two groups. 44% of nonagenarians had good discharge disposition, compared to 51% of patients <69 years (p=0.650) Conclusions We present one of the largest series of MT among nonagenarians with 89% successful recanalization rates. In propensity score analysis almost half of nonagenarians (44%) were discharged to home/rehab, which is comparable to a younger cohort (51%). Aggressive management is warranted in the oldest of the old

OBJECTIVE:To determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 mm Hg. METHODS:We retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from <160 to <140 mm Hg. The primary outcomes were presence of acute cerebral ischemia on MRI completed within 2 weeks of ICH and acute neurologic deterioration. RESULTS:= 0.022). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not. CONCLUSIONS:Intensive lowering of SBP <140 mm Hg in acute ICH, particularly allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration.

Introduction Elevated body mass index (BMI) and obesity have been associated with decreased mortality rates in hospitalized cardiac patients, and improved 3-month functional outcomes in patients with intracerebral hemorrhage. The mechanism for this association in unknown and validation in larger cohorts is lacking. Methods Prospectively collected data from intracranial hemorrhage patients (SAH, ICH and SDH) from two institutions were retrospectively reviewed for the association of BMI (evaluated continuously and in quartiles defined as underweight BMI<18.5, normal weight BMI 18.5-24.9, overweight BMI 25-29.9 and obese BMI>30) and 12-month mRS (dichotomized as 0-3 versus 4-6). Multivariable, backward, step-wise logistic regression models were constructed to evaluate the impact of BMI on outcome adjusting for bleed type, age, APACHE-2 score, admission NIHSS, black race, sex, diabetes, hypertension, baseline mRS and comfort care status. Results A total of 711 patients (N=275 SAH, 188 SDH, 311 ICH) were enrolled between 7/2008-5/2016. The median BMI was 27 (range 13-67), 4% were underweight, 33% normal weight, 33% overweight and 30% obese. Factors associated with increased BMI included younger age, diabetes, ICH or SAH (compared to SDH), black race, and worse baseline mRS (all P<0.05). Sex, income strata, history of cancer, hypertension, coronary artery disease, tobacco use, admission NIHSS and comfort care status were not significantly associated with BMI. The odds ratios (OR) for 12-month mRS 0-3 increased progressively across BMI quartiles (underweight OR 0.4, normal weight OR 0.6, overweight OR 1.3 and obese OR 1.6; P<0.001; ROC 0.594). In multivariable analysis, after adjusting for other factors, each quartile increase of BMI lead to a nearly two-fold improved odds of favorable 12-month outcome (aOR 1.8, 95% CI 1.3-2.4, P<0.001). Conclusions In intracranial hemorrhage patients, increasing BMI and obesity were associated with improved 12-month functional outcomes independent of baseline mRS, bleed type, age, race, sex, diabetes, hypertension, comfort care or admission clinical status