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Non traumatic Subdural Hemorrhage

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					Non-traumatic Subdural
     Hemorrhage
The impact of aspirin therapy and anticoagulation on the
prevalence of spontaneous subdural hematoma
                       ~Irish Medical Journal 93(8): 244-6, Nov. 2000
Effect of Intensity of Oral Anticoagulation on Stroke Severity
and Mortality in Atrial Fibrillation
                             ~NEJM, 349(11) : 1019-26, Sep. 11,2003
       Non-traumatic SDH
predisposing factor
- cerebral atrophy
- low CSF pressure (after a shunt or fistula)
- alcoholism
- coagulation disorders
The Impact of Aspirin therapy and
anticoagulation on the prevalence
of spontaneous subdural
haematoma


 ~Irish Medical Journal 93(8): 244-6, Nov. 2000
            Introduction
The prophylactic use of aspirin and
warfarin v.s. Spontaneous intracranial
hemorrhage
evaluate the prevalence of aspirin and
anticoagulant use in a cohort of surgical
patients with spontaneous subdural
haematoma
re-operation rates
Glasgow outcome scores of the six
months post hemorrhage status
               Methods
retrospective analysis of 200 patients who
received surgery for SDH
spontaneous and traumatic SDH
aspirin or anticoagulants usage from the pre-
operation notes
type of operation and the need of re-operation
outcome evaluation: Glasgow outcome score at
six months post surgery
routine hematological and biochemical profiles
at presentation
                             Results
  PREVELANCE
  SDH          Sex
               N      Mean Asp. War. Either None
  group        M:F    Age  (%) (%)    (%)    (%)
  Spontan. 123 68:55  74   78    15   93      30
                           (63) (12) (76)    (24)
  Traumat. 77 51:26 44     0(0) 5(6) 5(6)     72
                                             (94)
  Whole    200 119:80 63   78     20  98    102
                           (39) (10) (49)    (51)
INR for warfarinised patients with SDH was at 2.9
spontaneous acute SDH: 23/123(19%), aspirin/anticoagulants group: 20/23(87%)
               Results
The indication for aspirin/anticoagulant
use :
- cerebrovascular accident        43
- peripheral vascular disease 15
- myocardial infarction           12
- pulmonary embolus               10
- deep venous thrombosis           9
- artrial fibrillation             8
- unknown                         24
                         Results
   OPERATION and OUTCOME
Group           n     Burr Craniotomy Re-op      Mean
(spontaneous)        holes    (%)      (%)      GOS at
                      (%)                       6 mons.
aspirin         78   64(82)  14(18)   10(13)      3.8

warfarin        15   9(60)    6(40)    3(20)      3.5

either          93   73(78)   20(22)   13(14)     3.7

none            30   27(90)   3(10)     2(7)      4.4
              Results
Glasgow Outcome Scores (GOS)
1 = death
2 = persistent vegetative state
3 = severe disability
4 = minor disability
5 = full recovery
                Discussion
76% of the spontaneous subdural haematoma
cases were on aspirin or warfarin.
INR value in the spontaneous SDH group at 2.9
acute variety :
aspirin/anticoagulant group(22%) double to the non
anticoagulant group(10%)
re-op rates :
aspirin/anticoagulants group double to the non
anticoagulant group
outcomes :
aspirin/anticoagulants group was worsen than the
non-anticoagulant group
              Conclusion
Aspirin and anticoalualnts are responsible in part
for the pathogenesis of most cases of
spontaneous subdural haemorrhage and that
they may contribute significantly to the
associated morbidity.
Patients on aspirin and anticoagulants,
especially the elderly age group, should have
regular coagulation studies performed with
frequent review of the indications for use of
these agents.
Effect of Intensity of Oral Anticoagulation
on Stroke Severity and Mortality in Atrial
Fibrillation


    ~NEJM, 349(11) : 1019-26, Sep. 11,2003
             Introduction
nonvalvular atrial fibrillation v.s. ischemic
stroke
The effect of oral anticoagulants on the
frequency of stroke was proven, but how
about the severity and stroke-related
mortality ??
 comparison of the rates of ischemic
stroke and intracranial hemorrhage
according to the intensity of anticoagulants
               Methods
Definition of ischemic stroke :
 a neurologic deficit of sudden onset that
persisted for more than 24 hours
antithrombotic medicaiton and INR :
 - according the medication list
 - mean INR =average of each time routine
        data 6 months before stroke attack
The incidence of ischemic stroke and
intracranial hemorrhage according to the INR
among patients who were taking anticoagulant
agents.
                              Results
      Non-valvular Af and ischemic stroke
                               None       Aspirin    Warfarin
                              (n=248)    (n=160)     (n=188)
                               (42%)      (27%)       (32%)
Age                                 79     80            76
Cerebral atherosclerosis            2       7            4
Heart failure                       35     35            39
Coronary heart disease              30     32            36
DM                                  23     21            33
Hypertension                        70     58            70
Prior ischemic stroke               22     27            40
INR median / 25-75 p                -       -       1.7 / 1.3-2.2

62% of Warfarin-patient : INR<2.0
               Results
Severity of stoke and 30-day mortality
- severe stroke : 39% mortality
- major deficit : 13 %
- minor deficit : 1 %
- no neurologic sequelae : 0 %
                             Results
 Intensity of anticoagulation
                                    None   Aspirin   Warfarin   Warfarin
                                                     INR<2.0    INR≥2.0
                                                      (n=117)    (n=71)
Severity and outcome

Fata in-hospital stroke             14       6          9          1
Severe stroke, total dependence      8       7          6          4
Major stroke, neurologic deficit    37      36         44         38
that prevented independent living
Minor stroke, neurologic deficit    36      49         38         55
that that didn't prevented
independent living
No neurologic sequelae               5       2          3          2
Total 30-day mortality              24      15         16          6
               Results
Intensity of anticoagulation and rates of
stroke and intracranial hemorrhage
 - ischemic stroke : highest at INR< 2.0
               especially less than 1.5
 - intracranial hemorrhage :
   no marked absolute increase in the rate
   at INR less than 4.0
              Discussion
INR≥2.0 markedly reduces the severity of stroke
and the short-term mortality rate.
INR<2.0 three times of ischemic stroke to the
INR≥2.0
outcome of aspirin therapy : similar to INR<2.0
equally poor outcome between INR=1.5-1.9 and
INR< 1.5
worst outcome happen to those who received no
antithrombotic medication
                Discussion
use of anticoagulant therapy in patients with
atrial fibrillation an the target INR level :
- strokes that occur among patients with
  adequate anticoagulation are far less likely to
  result in severe disability or death
- INR<2.0 will substantially increase the
  likelihood of death and severe disability from
  atrial fibrillaiton-related stroke
- little additional risk of intracranial hemorrhage
   with the use of warfarin until INR>3.9
             Conclusion
the use of anticoagulation to achieve an
INR≥2.0 in patients with nonvalvular atrial
fibrillation
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posted:7/26/2011
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