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Venous thromboembolism prevention with low molecular weight heparin may reduce hemorrhagic transformation in acute ischemic stroke

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Abstract

Background

Subcutaneous heparin at a prophylactic dose (SHPD) is a rather common treatment in ischemic stroke, but whether it confers an increased risk of hemorrhagic transformation of cerebral infarct (HT) and whether its reduction or discontinuation favors HT regression are presently poorly understood.

Methods

Two samples of ischemic stroke patients with a cerebral lesion diameter ≥ 3 cm on brain CT scan, admitted over 7 years to our stroke unit, were retrospectively examined: (1) patients treated or not treated with SHPD (enoxaparin 4000 U/day), with subsequent assessment of possible HT appearance (N = 267, mean age 75.9 ± 12.8 years) and (2) patients treated with SHPD, with HT and subsequent reduction/discontinuation or maintenance of the initial dose, and subsequent assessment of HT evolution (N = 116, mean age 75.7 ± 11.1 years). HT severity was quantified according to the ECASS study (HT score).

Results

In the first sample, after adjustment for age, sex, stroke severity, cerebral lesion diameter, and other possible confounders, SHPD was inversely associated with HT appearance (hazard ratio 0.62, 95% CI 0.39–0.98, P = 0.04). In the second sample, after adjustment for age, sex, stroke severity, cerebral lesion diameter, and initial HT severity, SHPD reduction/discontinuation had an inverse effect on both HT score improvement (odds ratio 0.42, 95% CI 0.18–0.99, P = 0.049) and HT improvement according to neuroradiological reports (odds ratio 0.34, 95% CI 0.14–0.82, P = 0.015).

Conclusions

This retrospective study suggests that SHPD may play a protective role in HT appearance and evolution, which requires verification by a randomized clinical trial.

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Authors and Affiliations

  1. Stroke Unit – Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy

    Antonio Muscari, Giovanni M. Puddu & Marco Zoli

  2. Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

    Antonio Muscari, Elena Bartoli, Elena Franchi & Marco Zoli

  3. Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy

    Luca Faccioli, Marco Pastore Trossello & Luca Spinardi

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  1. Antonio Muscari
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  2. Elena Bartoli
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Correspondence to Antonio Muscari.

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Ethical approval

Because of the retrospective nature of this study, which included several patients who died after stroke, written informed consent could not be obtained. However, the utilization of the data derived from medical records for the present study was approved by our joint university-hospital Ethics Committee (Comitato Etico di Area Vasta Emilia Centro), and the study was conducted in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

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Muscari, A., Bartoli, E., Faccioli, L. et al. Venous thromboembolism prevention with low molecular weight heparin may reduce hemorrhagic transformation in acute ischemic stroke. Neurol Sci 41, 2485–2494 (2020). https://doi.org/10.1007/s10072-020-04354-0

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