15 de julho de 2013

Artigo recomendado: Perioperative Management of Coagulation in Nontraumatic Intracerebral Hemorrhage

Vincent Degos, Erick M. Westbroek, Michael T. Lawton, J. Claude Hemphill III, Gregory J. del Zoppo, William L. Young

Anesthesiology 2013; 119:218-27, Degos et al.

Approximately 70,000 new cases of spontaneous, nontraumatic intracerebral hemorrhage (ICH) occur annually in the United States. ICH is a significant cause of mortality throughout the Western world, with an estimated 30-day fatality rate of 30–50%. Surgical treatment is indicated for patients meeting specific criteria, and coagulation management is a crucial aspect of perioperative strategy.

Antithrombotic therapies are split into three categories such as antiplatelet agents (e.g., aspirin, clopidogrel), anticoagulant agents (e.g., warfarin, heparins), and fibrinolytic agents (e.g., recombinant tissue plasminogen activator). ICH can occur in the absence or the presence of any antithrombotic treatments. All antithrombotic agents have been associated with an increased risk of ICH in specific settings. Even though antiplatelet agents are the most commonly prescribed agents in the population, oral vitamin-K antagonists (VKAs) are a predominant cause of antithromboticassociated ICH. With the increased use of antithrombotic therapies, the incidence of antithrombotic-associated ICH appears to be increasing. Moreover, the use of new antithrombotic agents, such as the direct thrombin inhibitors and the oral factor Xa antagonists, is increasing. Specific strategies are recommended to reverse most antithrombotic treatments in the context of ICH.

Disagreements regarding the use of these reversal strategies will be discussed in this article. Intracranial hemorrhage, in the presence of underlying antithrombotic treatment, is thought to have a worse prognosis due to prolonged bleeding. Thus, anticoagulation reversal may provide a therapeutic opportunity. Although evidence for anticoagulation reversal directly impacting outcomes is scarce, this approach, a common element of care in neurological intensive care units, is known to have improved outcomes and is a part of the current ICH guidelines from the American Heart Association and the American Stroke Association with a Class I (level of evidence C).

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