<< Intracerebral Hemorrhage In Anticoagulated Patients: Evidence-Based Emergency Department Management (Stroke CME)

Controversies And Cutting Edge

TOC Will Appear Here

Controversies And Cutting Edge

Controversies And Cutting Edge

Novel Prehospital Computed Tomography Scanners

New mobile stroke units have recently been described in the literature. One such stroke unit, the mobile stroke team unit of Cleveland, has deployed an ambulance that has a registered nurse, paramedic, emergency medical technician, and a CT technologist. A stroke physician evaluates the patient and a neuroradiologist reads the images obtained in a noncontrast head CT. Point-of-care laboratory work is performed, and patients are able to receive tPA for ischemic stroke prior to hospital arrival. Likewise, patients with ICH may also be treated. Thus far, the mobile stroke unit has treated 1 prehospital anticoagulant-associated ICH with 4-factor PCC. The patient’s INR was initially 2.2, and was found to be 1.1, 106 minutes later.161 Although prehospital anticoagulation reversal is likely a long way off in most areas of the country, this method of ischemic and hemorrhagic stroke treatment is promising. PCCs are more ideal in the prehospital scenario as well, given that they are able to be stored at room temperature, unlike FFP, which requires refrigeration.105

Optic Nerve Sheath Diameter In Intracerebral Hemorrhage

Elevated ICP may be detectable with the use of optic nerve sheath diameter (ONSD) on ultrasound. Numerous studies have demonstrated the reliability of this method in ruling out elevated ICP in trauma.162 ONSD is performed by measuring 3 mm behind the eye over closed eyelids, as depicted in Figure 6.163 A study of 61 patients demonstrated that emergency physicians were able to accurately measure ONSD when compared to CT. In this study, the intraclass correlation coefficient was 0.9.164,165 The ONSD has a 100% sensitivity and specificity at 5.7 mm for high ICP, which was defined as > 20 mm Hg for more than 30 minutes.164 This may be a useful method to detect elevated ICP in the setting of ICH.

Figure 6_ Optic Nerve Sheath (Outlined In White)

Potential Antidotes For Novel Oral Anticoagulants

Potential antidotes are on the horizon for NOACs, and would be useful in the setting of NOAC-associated ICH. Andexanet alfa is a modified recombinant form of factor Xa, and binds to factor Xa inhibitors with an affinity similar to that of native factor Xa.166 Andexanet alfa is currently in phase 3 trials for the reversal of factor Xa inhibitors. Aripazine is in a phase 1 trial, and is being studied as a universal synthetic molecule that can bind to any anticoagulant to reverse its effects. Aripazine currently demonstrates no evidence of procoagulant effects.167

Publication Information

Natalie Kreitzer, MD; Opeolu Adeoye, MD, MS, FACEP, FAHA

Publication Date

December 1, 2015

CME Expiration Date

December 31, 2018

Get Permission

CME Information

Related Articles

An Evidence-Based Approach To Diagnosis And Management Of Subarachnoid Hemorrhage In The Emergency Department (Stroke CME) Emergency Medicine Practice - October 2014

Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndromes Part II: Evaluation And Management Of Acute Ischemic Stroke (Stroke CME) EM Practice Guidelines Update - August 2013

Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndromes Part I: Diagnosis And Evaluation Of Transient Ischemic Attack (Stroke CME) - EM Practice Guidelines Update - July 2013

Transient Ischemic Attack: An Evidence-Based Update (Stroke CME) Emergency Medicine Practice - January 2013

Four Evolving Strategies In The Emergent Treatment Of Acute Ischemic Stroke (Stroke CME) (FREE) Emergency Medicine Practice - July 2012

Carotid And Vertebral Arterial Dissections In The Emergency Department (Stroke CME) (Trauma CME) (FREE) Emergency Medicine Practice - April 2012

Emergency Management Of Coagulopathy In Acute Intracranial Hemorrhage (Stroke CME) (FREE) - EM Critical Care - April 2012

Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The Emergency Department (Stroke CME) (FREE) EM Practice Guidelines Update - January 2011

Get Quick-Read Evidence-Based Updates
Enter your email to get free evidence-based content delivered to your inbox once per month.
Please provide a valid email address.