When and how is possible hemostatic therapy in non anticoagulant-associated intracerebral haemorrhage

Hematoma volume is a major determinant of outcome in spontaneous intracerebral haemorrhage (ICH) and its secondary expansion occurs frequently and early with the potential sequelae of rostrocaudal deterioration or death. Therefore, early restriction of ICH volume is of paramount importance. Although few indications appear to be available for neurosurgical measures, nonsurgical measures such as reduction of hypertension and normalisation of altered coagulation seem to be beneficial. However, the routinary use of coagulation factors outside of anticoagulant-associated spontaneous ICH cannot generally be recommended at present. Future trials on recombinant coagulation factor VIIa with stricter selection criteria of inclusion time window, ICH and intraventricular haemorrhage volume, and age of patients are needed

Non-traumatic splenic rupture on dual antiplatelet therapy with aspirin and ticagrelor after stenting for acute coronary syndrome

AbstractWe report a case of non-traumatic splenic rupture in a 57-year-old man on dual antiplatelet therapy (DAPT) with aspirin and ticagrelor, seven months after percutaneous coronary intervention and drug-eluting stent implantation for non-ST elevation myocardial infarction. No splenic abnormalities were found at histopathological analysis after splenectomy, and no history of recent trauma was reported. Once restarted, DAPT after splenectomy, assessment of platelet function was performed by light transmittance aggregometry, showing a profound inhibition of platelet function by adenosine diphosphate, arachidonic acid, and collagen. Taking into account the bleeding risk associated with low on-treatment platelet reactivity, and to switch the patient from ticagrelor to a less potent P2Y12 inhibitor such as clopidogrel, cytochrome P450, genetic polymorphisms accounting for clopidogrel response variability were analyzed. The polymorphisms associated with lower response (CYP2C19*2, CYP2C19*3) were absent. Therefore, ticagrelor was withdrawn, and DAPT was continued with aspirin and clopidogrel. Rupture of the spleen may occur in the absence of major trauma or previous splenic diseases, and could be a complication of antithrombotic treatments. Moreover, low on-treatment platelet reactivity during DAPT is emerging as a possible risk factor for bleeding complications, so underlining the usefulness of assessing platelet function in special conditions to ensure that the patient receives the best tailored antiplatelet therapy.<Learning objective: Non-traumatic splenic rupture is a rare event, and is more often associated with pre-existing splenic abnormalities. However, it may be also a complication of medical treatments, especially with antithrombotic drugs. Low on-treatment platelet reactivity is emerging as a possible risk factor for bleeding complications; therefore, assessing platelet function in special conditions could be useful to ensure the patient receives the best-tailored antiplatelet therapy.

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

The balance between the risk of early stroke recurrence and hemorrhagic transformation represents the cornerstone of practical management of non-valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS). Patients who receive antithrombotic therapy as secondary prevention in the early phase of NVAF-related AIS have a better prognosis compared with patients who do not receive antithrombotic treatment. Recently, the RAF study showed that the best efficacy/safety profile was associated with anticoagulation started between 4 and 14 days from stroke onset. Based on the RAF study, the 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest starting anticoagulants between 4 and 14 days from stroke onset with a class of recommendation IIa. Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. However, the real life evidence suggests that early starting time of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality. In the present review the Authors provide an update on anticoagulation in the early phase of NVAF-related AIS with focus on DOACs