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Treating Thrombotic Complications in Patients with Primary Intracerebral Haemorrhage

OBJECTIVE
To find out how physicians would manage thrombotic complications in patients with primary intracerebral haemorrhage.


DESIGN
Fifty-six participants at a British Geriatrics Society session on stroke were asked to state on a self-completion question sheet how they would manage two hypothetical cases.


RESULTS
There was support for a wide range of treatments but no consensus on how to treat patients with life-threatening thrombosis after cerebral haemorrhage.

Deep venous thrombosis (DVT) is a common complication of stroke and may lead to potentially fatal pulmonary embolism (PE). DVT is often clinically silent1 but scinti graphic studies have shown incidences of 56% and 72%2-3. The risk of death from an untreated pulmonary embolism is about 30%4,5 and both DVT and PE are usually treated by anticoagulation. However, this may be risky in patients who have had a primary intracerebral haemorrhage (PICH), the cause of approximately 10% of strokes in the United Kingdom6. In the Oxfordshire Community Stroke Project, 21% of deaths in patients with PICH were attributed to the complications of immobility, including pulmonary embolus7. Thrombotic complications in patients with PICH therefore pose a treatment dilemma. Many physicians have had to face this treatment dilemma and I wondered how they would treat such patients. My hypothesis was that there would be no consensus on treatment.

Methods
Two clinical situations, each with two components (a and b), were presented on paper to physicians visiting a poster display at a meeting of the British Geriatrics Society. The scenarios are shown in Table 1.
Participants were asked to indicate on the self-completion questionnaire which treatments they would use. A 'yes or no' answer was required for each treatment option. Compo nent (b) of each case was on the back of the page on which component (a) was presented and subjects were asked to complete component (a) first. They were also asked their grade and special interest.
Results were analysed using non-parametric statistics and expressed as percentages, with 95% confidence intervals (CI).

Results
Fifty-six completed questionnaires were received. Forty were from consultants and the remainder from specialist registrars. Thirteen had a special interest in stroke. The responses are shown in Table 2. In only 9 of a possible 1,064 responses was no definite response given.

Treatments given
The most widely agreed treatment was anti-embolism stockings for DVT. Several doctors commented that they did not know how to get an inferior vena cava (IVC) filter inserted in their hospital. Twenty-five per cent (95% CI 14-38%) said they would use some drug treatment for DVT eight days after a cerebral haemorrhage. Overall, 14% (95% CI 6-26%) of respondents would not use antithrombotic treatment in any circumstance after PICH, whereas 5% (95% CI 1-15%) would use intravenous heparin and warfarin in all the clinical situations described.

Discussion
There was no consensus among participants in this study as to how patients with thrombotic complications after PICH should be treated. The sample, although small, was repre sentative of UK physicians treating stroke8. They agreed on treatment in some areas: anti-embolism stockings were widely used after DVT, possibly because they do not carry any extra risk. A high number of physicians said they would use IVC filters, although many had clearly never used this treatment. The design of the questionnaire may have influ enced replies to this item because respondents may have read scenario lb before completing la, although this was on the other side of the paper. There were widely differing opinions on anticoagulation with heparin or warfarin: some physicians said they would treat patients with DVT eight days after PICH, while others said they would not do so even in the presence of a definite pulmonary embolus three weeks after the stroke. Overall, there was a trend to use more intensive anticoagulation when more time had elapsed from the onset of the haemorrhage. This broad range of opinions suggests a lack of reliable data.
To estimate the risks and benefits of treatment with various antithrombotic or anticoagulant treatments, the risk of death or rebleeding after a PICH, and how this is altered by such treatments, must be known. The risk of sponta- Passero et al9 prospectively followed 112 survivors of PICH for a mean of 84 (range 1-189) months. Twenty-seven had one or more instances of rebleeding and 14 suffered either a cerebral infarct or a transient ischaemic attack. Eight of the recurrent haemorrhages occurred in the first year. Melo et al10 prospectively followed 306 patients from a total cohort of 515 who survived 30 days after PICH. Four were lost to follow-up and 21 had recurrent strokes after two years: 11 were haemorrhages, five were ischaemic, and in five the type of stroke was unknown. From these studies it becomes clear that recurrent bleeding is not common after PICH and a large clinical survey would be needed to detect even a moderate increase in incidence. Ischaemic strokes occur nearly as often in this population. Heparin has been used in two small trials in an attempt to prevent thrombosis after PICH. In one, 46 patients were randomly allocated to receive 5,000 units of subcutaneous unfractionated heparin three times daily, starting either four or ten days after PICH11. Nine of the 23 treated at ten days developed some evidence of a PE compared with five treated at four days. In a subsequent non-randomised study12, earlier treatment reduced the incidence of PE. Both trials are open to a number of serious criticisms and were far too small to show whether the benefits of treatment out weigh the risks. The Cochrane Collaboration is currently reviewing the use of heparin in PICH13. Analysis of recent large stroke trials may also provide data. Little evidence is available for deciding how best to treat patients with a cerebral haemorrhage who subsequently develop a serious thrombotic complication. At present, physicians have little option but to continue to do this on a pragmatic basis for each patient.