G. Morgan Jones, BCPS, PharmD
Clinical Pharmacy Specialist - Neurocritical Care
Methodist LeBonheur Healthcare
Germantown, Tennessee, United States
Disclosure information not submitted.
Aaron Cook, BS
Research Coordinator
Henry Ford Hospital, United States
Disclosure information not submitted.
Sayona John, MD
Medical Director, Neuroscience Intensive Care Unit & Neuroemergency Transfer Program
Rush University Medical Center, United States
Disclosure information not submitted.
Nicholas Panos, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist, Neuroscience Intensive Care
Rush University Medical Center, United States
Disclosure information not submitted.
Title: Catheter Tract Hemorrhage in Patients with FXa Inhibitor Associated ICH treated with PCC
Introduction: Rate of catheter tract hemorrhage (CTH) following external ventricular drain (EVD) placement ranges from 10-34%. However, there are no evaluations of CTH rates in patients following factor Xa (FXa) inhibitor-associated intracranial hemorrhage (ICrH) in those treated with prothrombin complex concentrate (PCC). Given this, we aimed to evaluate rates of CTH in patients undergoing EVD placement following treatment with PCC for FXa inhibitor-related ICrH.
Methods: This was a retrospective cohort study of patients with FXa inhibitor-related ICrH who had an EVD placed after receiving PCC. All patients were treated at one of 17 stroke centers from Jan 1, 2015 - March 1, 2019. The efficacy assessment evaluated each brain image completed in the 24 hours following PCC administration for the presence of any CTH. A provider at each site with specialty training in neuroimaging completed review of each patient’s imaging. The safety assessment evaluated for the occurrence of a thrombotic event, which was censored at hospital discharge or 30 days following PCC administration.
Results: We included 55 patients. Median age was 69 (25%-75% IQR 63-76) years with a median admission Glasgow Coma Scale score of 9 (7-13). A total of 58.2% of patients had a primary intracerebral hemorrhage and 14.5% had a traumatic hemorrhage. The majority of patients (80%) received non-activated PCC (median dose 43.1 units/kg [31.5-52.8]), with the remaining 20% receiving activated PCC (median dose 43.1 [26.0-48.1]). Median time from PCC charting to EVD placement was 2.5 (1.5-6.3) hours. CTH occurred in 3 patients (5.5%), all of whom were taking apixaban prior to admission and who received non-activated PCC. Five patients (9.1%) experienced 6 thrombotic events (2 deep vein thrombosis and 4 ischemic strokes). In-hospital mortality was 40.0% and the median intensive care unit and hospital length of stay were 10.8 (6.0-16.1) and 12.4 (6.5-21.7) days, respectively.
Conclusions: Administration of PCC after apixaban and rivaroxaban-related ICH and prior to EVD placement resulted in a low rate of CTH. We believe our data support use of PCC as a reasonable option for those anticoagulated with an oral FXa inhibitor who require an urgent procedure. Further evidence is needed to determine adequate agent and dose needed to optimize safety and efficacy.