Abstract
Background and Objectives: Large hemispheric infarctions (LHI) are associated with significant morbidity and mortality, with limited data on therapeutic anticoagulation (AC) management. We provide a descriptive analysis of timing and type of therapeutic AC introduction, rate of radiographic versus symptomatic hemorrhagic transformation (HT), and patient outcomes.
Methods: Retrospective review of acute ischemic stroke patients admitted to the Neurosciences ICU at a tertiary care center from January 2012 to December 2018. Inclusion criteria included admission imaging with stroke size > ⅔ of middle cerebral artery territory, +/- other vascular territory and need for therapeutic AC. HT categories included hemorrhagic infarction types 1 and 2 and parenchymal hematoma types 1 and 2. Primary outcome included HT with and without an associated clinical change. Secondary outcomes included disposition at discharge, mRS at discharge and at follow-up when available.
Results: 2,317 patients were screened, 380 met inclusion criteria for LHI and 105 received AC. Mean age 64 years (SD 16.8) and 50% (n= 53) female. Mean admission NIHSS 20 (SD 5.9). Mean poststroke timing to initiation of AC was 17 days (SD 10.1) (median 14 [IQR 10-19]). Indications for AC included atrial fibrillation (51%), cardiac thrombus (19%), venous thromboembolism (19%), other (10%). Heparin was most common in the very early (<7 days) group (n=11, 79%); while vitamin K antagonists without a bridge was most common among entire cohort (n=54, 51%). Radiographic HT was seen in 68 patients (65%) prior to AC initiation. After initiation of AC, 70 patients had repeat imaging, with 6 cases (6%) of worsening radiographic HT and 4 cases (4%) of symptomatic deterioration, of which 3 required reversal of AC. At discharge, 7 patients (7%) had a good outcome (mRS 0-2).
Conclusions: While radiographic HT is common among LHI patients, it does not always portend symptomatic clinical deterioration. Further research regarding AC timing and safety is necessary.
- © 2022 American Academy of Neurology
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