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Antiplatelet therapy, but not intravenous thrombolytic therapy, is associated with postoperative bleeding complications after decompressive craniectomy for stroke

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Abstract

Intravenous thrombolysis (IVT) is an established treatment in patients suffering from acute ischemic stroke (AIS). IVT might increase the risk of postoperative complications if applied prior to decompressive craniectomy (DC). Therefore, we analyzed the management of patients with and without IVT prior to DC. Between 1999 and 2011, DC was performed in 115 patients after AIS. Patients with and without IVT prior to DC were compared regarding perioperative management, postoperative complications and outcome. Postoperative complications were stratified into non-bleeding and bleeding complications. Outcome was assessed using the modified Rankin scale after three months. Two multivariate analyses were performed to identify predictors for postoperative complications and predictors for unfavourable outcome (mRS 4–6). Fifty-two of 115 patients underwent IVT prior to DC (45 %). Forty-four patients were on antiplatelet therapy prior to DC (38 %). Frequency of bleeding complications did not differ significantly in patients with IVT prior to DC compared to patients without. However, bleeding complications occurred significantly more often in patients with antiplatelet use prior to DC (p = 0.0003, OR 4.5). In the multivariate analysis “preoperative use of acetylsalicylic acid” was the only independent predictor associated with bleeding complications (p = 0.002, OR 3.9). IVT prior to DC did not predict unfavourable outcome. There was no evidence in this observational study that IVT prior to DC places patients at undue risk of bleeding complications after subsequent DC. Patients with or without IVT prior to DC suffered significantly more often from postoperative bleeding complications if antiplatelet therapy was applied before onset of AIS.

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References

  1. Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38(9):2518–2525

    Article  PubMed  Google Scholar 

  2. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, Bousser MG, van der Worp HB, Hacke W (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6(3):215–222

    Article  PubMed  Google Scholar 

  3. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W (1998) Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29(9):1888–1893

    Article  PubMed  CAS  Google Scholar 

  4. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr (2009) Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke 40(8):2945–2948

    Article  PubMed  Google Scholar 

  5. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317–1329

    Article  PubMed  CAS  Google Scholar 

  6. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333(24):1581–1587

    Article  Google Scholar 

  7. Kwiatkowski TG, Libman RB, Frankel M, Tilley BC, Morgenstern LB, Lu M, Broderick JP, Lewandowski CA, Marler JR, Levine SR, Brott T (1999) Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med 340(23):1781–1787

    Article  PubMed  CAS  Google Scholar 

  8. Wahlgren N, Ahmed N, Davalos A, Hacke W, Millan M, Muir K, Roine RO, Toni D, Lees KR (2008) Thrombolysis with alteplase 3–4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet 372(9646):1303–1309

    Article  PubMed  CAS  Google Scholar 

  9. Fischer U, Taussky P, Gralla J, Arnold M, Brekenfeld C, Reinert M, Meier N, Mono ML, Schroth G, Mattle HP, Nedeltchev K (2011) Decompressive craniectomy after intra-arterial thrombolysis: safety and outcome. J Neurol Neurosurg Psychiatry 82(8):885–887

    Article  PubMed  Google Scholar 

  10. Chalela JA, Katzan I, Liebeskind DS, Rasmussen P, Zaidat O, Suarez JI, Chiu D, Klucznick RP, Jauch E, Cucchiara BL, Saver J, Kasner SE (2001) Safety of intra-arterial thrombolysis in the postoperative period. Stroke 32(6):1365–1369

    Article  PubMed  CAS  Google Scholar 

  11. Goldstein JN, Marrero M, Masrur S, Pervez M, Barrocas AM, Abdullah A, Oleinik A, Rosand J, Smith EE, Dzik WH, Schwamm LH (2010) Management of thrombolysis-associated symptomatic intracerebral hemorrhage. Arch Neurol 67(8):965–969

    Article  PubMed  Google Scholar 

  12. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M (2007) Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation 116(16):e391–e413

    Article  PubMed  Google Scholar 

  13. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24(1):35–41

    Article  PubMed  Google Scholar 

  14. European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee (2008) Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 25(5):457–507

    Article  Google Scholar 

  15. Güresir E, Vatter H, Schuss P, Oszvald A, Raabe A, Seifert V, Beck J (2011) Rapid closure technique in decompressive craniectomy. J Neurosurg 114(4):954–960

    Article  PubMed  Google Scholar 

  16. Schuss P, Vatter H, Marquardt G, Imöhl L, Ulrich CT, Seifert V, Güresir E (2012) Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications. J Neurotrauma 29(6):1090–1095

    Article  PubMed  Google Scholar 

  17. Ueda T, Sakaki S, Kumon Y, Ohta S (1999) Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke. Stroke 30(11):2360–2365

    Article  PubMed  CAS  Google Scholar 

  18. Glader EL, Stegmayr B, Norrving B, Terent A, Hulter-Asberg K, Wester PO, Asplund K (2003) Sex differences in management and outcome after stroke: a Swedish national perspective. Stroke 34(8):1970–1975

    Article  PubMed  Google Scholar 

  19. Shinton R, Beevers G (1989) Meta-analysis of relation between cigarette smoking and stroke. BMJ 298(6676):789–794

    Article  PubMed  CAS  Google Scholar 

  20. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P (2004) The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 44(4):398–404

    Article  PubMed  CAS  Google Scholar 

  21. Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22(8):983–988

    Article  PubMed  CAS  Google Scholar 

  22. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337(8756):1521–1526

    Article  PubMed  CAS  Google Scholar 

  23. Takeuchi S, Wada K, Nawashiro H, Arimoto H, Ohkawa H, Masaoka H, Otani N, Takasato Y (2012) Decompressive craniectomy after intravenous tissue plasminogen activator administration for stroke. Clin Neurol Neurosurg

  24. Collen D, Lijnen HR (2005) Thrombolytic agents. Thromb Haemost 93(4):627–630

    PubMed  CAS  Google Scholar 

  25. Fassbender K, Dempfle CE, Mielke O, Schwartz A, Daffertshofer M, Eschenfelder C, Dollman M, Hennerici M (1999) Changes in coagulation and fibrinolysis markers in acute ischemic stroke treated with recombinant tissue plasminogen activator. Stroke 30(10):2101–2104

    Article  PubMed  CAS  Google Scholar 

  26. Diedler J, Ahmed N, Sykora M, Uyttenboogaart M, Overgaard K, Luijckx GJ, Soinne L, Ford GA, Lees KR, Wahlgren N, Ringleb P (2010) Safety of intravenous thrombolysis for acute ischemic stroke in patients receiving antiplatelet therapy at stroke onset. Stroke 41(2):288–294

    Article  PubMed  CAS  Google Scholar 

  27. Uyttenboogaart M, Koch MW, Koopman K, Vroomen PC, De Keyser J, Luijckx GJ (2008) Safety of antiplatelet therapy prior to intravenous thrombolysis in acute ischemic stroke. Arch Neurol 65(5):607–611

    Article  PubMed  Google Scholar 

  28. The NINDS t-PA Stroke Study Group (1997) Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 28(11):2109–2118

    Article  Google Scholar 

  29. Zinkstok SM, Roos YB (2012) Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial. Lancet 380(9843):731–737

    Article  PubMed  CAS  Google Scholar 

  30. Larrue V, von Kummer RR, Muller A, Bluhmki E (2001) Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke 32(2):438–441

    Article  PubMed  CAS  Google Scholar 

  31. Ciccone A, Motto C, Aritzu E, Piana A, Candelise L (1998) Risk of aspirin use plus thrombolysis after acute ischaemic stroke: a further MAST-I analysis. MAST-I Collaborative Group. Multicentre Acute Stroke Trial–Italy. Lancet 352(9131):880

    Article  PubMed  CAS  Google Scholar 

  32. Wahlgren N, Ahmed N, Eriksson N, Aichner F, Bluhmki E, Davalos A, Erila T, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kohrmann M, Larrue V, Lees KR, Machnig T, Roine RO, Toni D, Vanhooren G (2008) Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke 39(12):3316–3322

    Article  PubMed  Google Scholar 

  33. Harder S, Klinkhardt U (2000) Thrombolytics: drug interactions of clinical significance. Drug Saf 23(5):391–399

    Article  PubMed  CAS  Google Scholar 

  34. Li X, Sun Z, Zhao W, Zhang J, Chen J, Li Y, Ye Y, Zhao J, Yang X, Xiang Y, Li G, Mao J, Zhang W, Zhang M (2012) Effect of acetylsalicylic acid usage and platelet transfusion on postoperative hemorrhage and activities of daily living in patients with acute intracerebral hemorrhage. J Neurosurg 118(1):94–103

    PubMed  Google Scholar 

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The authors declare that they have no conflict of interest.

Ethical standard

This study was conducted according to the standards of the local ethics committee.

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Authors and Affiliations

  1. Department of Neurosurgery, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany

    Patrick Schuss, Valeri Borger, Hartmut Vatter, Volker Seifert & Erdem Güresir

  2. Department of Neurology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany

    Oliver C. Singer

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  1. Patrick Schuss
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  2. Valeri Borger
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  3. Hartmut Vatter
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  4. Oliver C. Singer
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  5. Volker Seifert
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Correspondence to Patrick Schuss.

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Schuss, P., Borger, V., Vatter, H. et al. Antiplatelet therapy, but not intravenous thrombolytic therapy, is associated with postoperative bleeding complications after decompressive craniectomy for stroke. J Neurol 260, 2149–2155 (2013). https://doi.org/10.1007/s00415-013-6950-y

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  • DOI: https://doi.org/10.1007/s00415-013-6950-y

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