Faculty Bibliography

BACKGROUND:The risk of intracerebral hemorrhage (ICH) hematoma expansion (HE) is highest in the first hours after onset, and coagulopathy is believed to further increase this risk. However, there is a paucity of data comparing the risk of HE over time for various antithrombotic agents. METHODS:We conducted a retrospective study of spontaneous ICH patients enrolled at a comprehensive stroke center between December 2016 and May 2022, excluding those who underwent surgical evacuation. ICH volumes were calculated using ABC/2 methodology and HE was coded for a ≥ 33% and/or ≥ 6-mL increase in ICH volume. Multivariable logistic regression and Cox proportional hazards models were constructed to evaluate risk of HE among patients exposed to the following antithrombotics: aspirin, P2Y12 inhibitors, aspirin + P2Y12 inhibitors, warfarin, oral factor Xa inhibitors, direct thrombin inhibitors, full dose heparinoids, and combined antiplatelet + anticoagulant. RESULTS:Of 319 patients with ICH, 141 (44%) were on an antithrombotic at the time of ICH and 65 (20%) had HE in a median of 10 h (interquartile range (IQR) 7-21) from last known normal (LKN). In multivariable logistic regression analyses, the odds of HE decreased by 2% for every hour from LKN (adjusted odds ratio (aOR) 0.98, 95% CI 0.97-0.99, P = 0.038), and HE occurred significantly more often in patients taking combined antiplatelet + anticoagulant (9/24, 38%) compared with those who were not (56/295, 19%, aOR 2.71, 95% CI 1.09-6.73, P = 0.032). No other antithrombotic was significantly associated with HE. In multivariable Cox analysis adjusting for admission National Institutes of Health Stroke Scale (NIHSS), only antiplatelet + anticoagulant use was associated with significantly increased rates of HE (adjusted HR (aHR) 2.33, 95% CI 1.14-4.75, P = 0.020), with the highest probability of HE occurring immediately after ICH onset. CONCLUSIONS:Use of combined antiplatelet + anticoagulant was associated with a twofold increased hazard of HE, with the highest probability of expansion occurring early after ICH onset. No increased rate of HE was observed for other antithrombotics.

OBJECTIVE The authors sought to determine the effects of eliminating the use of prolonged prophylactic systemic antibiotics (PPSAs) in patients with subdural and subgaleal drains. METHODS Using a retrospective database, the authors collected data for patients over the age of 17 years who had undergone cranial surgery at their institution between December 2013 and July 2014 (PPSAs period) or between December 2014 and July 2015 (non-PPSAs period) and had subdural or subgaleal drains left in place postoperatively. RESULTS One hundred five patients in the PPSAs period and 80 in the non-PPSAs period were identified. The discontinuation of PPSAs did not result in an increase in the frequency of surgical site infection (SSI). The frequency of Clostridium difficile (CDI) and the growth of resistant bacteria were reduced in the non-PPSAs period in comparison with the PPSAs period. In the 8 months after the drain prophylaxis protocol was changed, $93,194.63 were saved in the costs of antibiotics and complications related to antibiotics. CONCLUSIONS After discontinuing PPSAs for patients with subdural or subgaleal drains at their institution, the authors did not observe an increase in the frequency of SSI. They did, however, note a decrease in the frequency of CDI and the growth of resistant organisms. It appears that not only can patients in this population do without PPSAs, but also that complications are avoided when antibiotic use is limited to 24 hours after surgery.