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1.
J Cardiovasc Pharmacol Ther ; 28: 10742484231202655, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37872658

RESUMO

The indications of direct oral anticoagulants (DOACs) have expanded over the past 15 years. DOACs are effective and safe oral anticoagulants associated with lower bleeding risks and mortality than vitamin K antagonists. However, DOAC users are prone to a considerable bleeding risk, which can occur at critical sites or lead to severe life-threatening conditions. Recent statistics indicated that major bleeding occurs in up to 6.62 DOAC users per 100 treatment years. With the increased use of DOACs in clinical practice, DOAC-associated major bleeding is expected to be encountered more frequently in the emergency department. The current international guidelines recommend specific reversal agents for the management of DOAC users with severe bleeding to reverse the anticoagulant effect and restore normal hemostasis. An individualized assessment was incorporated in specific clinical situations to guide the decision pathway of major bleeding management. However, specific reversal agents are unavailable or have limited availability in many countries, which is expected to negatively impact the clinical outcomes of DOAC-associated major bleeding. Limited real-world evidence is available from these countries regarding the clinical outcomes of patients with DOAC-associated major bleeding. This narrative review provided an updated assessment of the evidence-based approaches for the management of major bleeding in DOAC users. We also explored the clinical outcomes of patients with major bleeding from clinical settings where specific reversal agents are unavailable.


Assuntos
Anticoagulantes , Hemorragia , Humanos , Hemorragia/induzido quimicamente , Anticoagulantes/efeitos adversos , Administração Oral , Dabigatrana/efeitos adversos
2.
Cureus ; 14(9): e29392, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36304377

RESUMO

Rapidly progressive dementia is an uncommon neurological presentation and usually needs extensive workup, especially for reversible causes. Dural arteriovenous fistula (DAVF) has been rarely reported as a cause of thalamic dementia, in which bilateral thalamic venous congestion and edema cause dementia that usually progresses rapidly. We present a case of a 45 years-old male who presented with rapidly progressive severe attention and memory impairment over one week. Initial work-up showed bilateral thalamic recent venous infarctions and edema. Extensive work-up revealed an intracranial DAVF with internal deep venous thrombosis. Management with endovascular treatment of DAVF followed by anticoagulation for venous thrombosis leads to improvement of the patient's clinical condition, particularly memory and attention. In conclusion, DAFV could present with thalamic rapidly progressive dementia due to bithalamic infarctions and edema. Early diagnosis and treatment will reverse the cause and improve the patient's general and cognitive conditions.

3.
Cureus ; 12(7): e9183, 2020 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-32802618

RESUMO

Cervicocerebral artery dissection (CAD) is an important and under-recognized cause of strokes in young and middle-aged patients. Spontaneous vertebral artery dissection (VAD) is a rare condition that can potentially cause a stroke without any preceding trauma or other causes of dissection. VAD rarely simulates classical headache syndromes. In this report, we discuss two young patients who were initially misdiagnosed as cases of headache until they presented with ischemic events, and were eventually diagnosed with spontaneous VAD. Case 1 involves a 41-year-old male patient who presented with severe headache radiating to left posterior neck pain and dizziness. He was initially misdiagnosed as a case of cervicogenic headache. He was subsequently diagnosed with extracranial VAD complicated by a delayed embolic ischemic stroke. However, he made full recovery within the next few days. Case 2 pertains to a 33-year-old female patient who presented with right-sided headache mimicking migraine; later on, new neurological signs prompted a diagnosis of acute ischemic infarction as a complication of intracranial VAD. In conclusion, VAD should be seriously considered when dealing with patients complaining of the first attack of headache that mimics migraine or those with cervicogenic headaches, which fail to respond to the usual treatment. Moreover, posterior circulation stroke among young patients or stroke with pain in the head and neck should be investigated carefully with extensive neuroimaging. Finally, prompt and accurate diagnosis of VAD followed by proper treatment is crucial for good outcomes and will prevent disability or even fatal complications in patients.

4.
Int J Stroke ; 10(4): 501-5, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25472690

RESUMO

BACKGROUND: Clopidogrel combined with aspirin is routinely prescribed after coronary artery stenting, in patients with acute coronary syndromes, and recently to prevent stroke in patients with acute minor ischemic stroke and TIA. Subdural hematomas are an important complication of antithrombotic treatment, but the risk associated with clopidogrel plus aspirin has not been previously defined. PURPOSE: To quantify the risk of subdural hematoma associated with dual antiplatelet therapy with clopidogrel plus aspirin. METHODS: Randomized clinical trials comparing clopidogrel plus aspirin with aspirin alone were identified by searching the Cochrane Central Register of Controlled Trials from 1990 to 2014, and restricted to those with more than 7 days of treatment. Two reviewers independently extracted data about subdural hematomas. RESULTS: Of 24 randomized trials testing clopidogrel added to aspirin, results for subdural hematoma were available for 11 trials, of which eight did not identify any subdural hematomas. The three trials reporting subdural hematomas were double-blind and included patients with recent lacunar stroke, acute coronary syndromes or atrial fibrillation with a total of 23,136 patients (mean age 66 years) and reported 39 subdural hematomas during a mean follow-up 2.1 years per patient. Clopidogrel plus aspirin was associated with a significantly increased risk of subdural hematoma compared with aspirin alone (risk ratio 2.0, 95% CI 1.0, 3.8; P = 0.04; fixed effects model; I2 for heterogeneity of 0%, P = 0.51). The average absolute incidence of subdural hematoma averaged 1.1 (95% CI 0.7,1.6) per 1000 patient - years among those assigned clopidogrel plus aspirin in 11 randomized trials. CONCLUSIONS: The absolute rate of subdural hematoma during dual antiplatelet therapy is low, averaging 1.1 per 1000 patient-years. Chronic treatment with clopidogrel plus aspirin significantly increases the risk of subdural hematoma compared with aspirin alone.


Assuntos
Aspirina/uso terapêutico , Hematoma Subdural/epidemiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Fibrilação Atrial/tratamento farmacológico , Clopidogrel , Quimioterapia Combinada , Feminino , Hematoma Subdural/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral Lacunar/tratamento farmacológico , Ticlopidina/uso terapêutico
5.
J Stroke Cerebrovasc Dis ; 23(4): 618-24, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23800503

RESUMO

BACKGROUND: Among participants in the Secondary Prevention of Small Subcortical Strokes randomized trial, we sought to identify patients with high versus low rates of recurrent ischemic stroke and to assess effects of aggressive blood pressure control and dual antiplatelet therapy according to risk status. METHODS: Multivariable analyses of 3020 participants with recent magnetic resonance imaging-defined lacunar strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes. RESULTS: Prior symptomatic lacunar stroke or transient ischemic attack (TIA) (hazard ratio [HR] 2.2, 95% confidence interval [CI] 1.6, 2.9), diabetes (HR 2.0, 95% CI 1.5, 2.5), black race (HR 1.7, 95% CI 1.3, 2.3), and male sex (HR 1.5, 95% CI 1.1, 1.9) were each independently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of 4.3% per year (95% CI 3.4, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the cohort), 3.1% per year (95% CI 2.6, 3.9) in those with more than 1 of the other 3 risk factors (27% of the cohort), and 1.3% per year (95% CI 1.0, 1.7) in those with 0-1 risk factors (58% of the cohort). There were no significant interactions between treatment effects and stroke risk status. CONCLUSIONS: In this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood pressure management, prior symptomatic lacunar ischemia, diabetes, black race, and male sex independently predicted ischemic stroke recurrence. The effects of blood pressure targets and dual antiplatelet therapy were similar across the spectrum of independent risk factors and recurrence risk.


Assuntos
Acidente Vascular Cerebral Lacunar/epidemiologia , Acidente Vascular Cerebral Lacunar/terapia , Adulto , Idoso , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/prevenção & controle , Isquemia Encefálica/terapia , Feminino , Seguimentos , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/terapia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Prevenção Secundária , Acidente Vascular Cerebral Lacunar/prevenção & controle , Resultado do Tratamento
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