Faster treatment of brain hemorrhages increases chances of survival, new study finds

Taking a blood thinner or anticoagulant medication may increase or exacerbate the risk of a brain hemorrhage, also known as a cerebral hemorrhage, which is the most deadly type of stroke. Now, new research reveals that faster treatment for these patients is associated with a greater likelihood of survival.

A hemorrhagic stroke occurs when a weakened blood vessel ruptures and causes bleeding in the brain. About 20% of patients with brain hemorrhages take an anticoagulant, such as warfarin, rivaroxaban, dabigatran, and apixaban. These anticoagulants are commonly used to treat cardiovascular diseases such as atrial fibrillation (an irregular heartbeat) and chronic and acute blood clotting disorders.

“Oral anticoagulants are highly effective and important population medications that individuals need. Therefore, it is important to know the individual risk, which is uncommon but serious,” says Kevin Sheth, MD, professor of neurology and neurosurgery at the Yale School. of Medicine. “Our health systems must be prepared and ready to act quickly when something goes wrong.”

Over the past decade, scientists have developed reversal agents for specific anticoagulants, including idarucizumab for dabigatran in 2015 and andexanet alfa for rivaroxaban and apixaban in 2018. These are generally administered in hospital emergency departments and can save the lives of people suffering from brain hemorrhages.

Now, using a large set of real-world data, researchers have shown that delivering these treatments more quickly can increase a patient’s chances of survival. The researchers published their results in JAMA Neurology on February 9.

“As these reversal treatments have emerged, experts have questioned whether it is better to proceed earlier,” says Sheth, first author of the study. “This article, for the first time, demonstrates that this is the case.”

There are two main types of stroke: bleeding (brain hemorrhages) and clotting. An (ischemic) stroke occurs when clots block blood flow to the brain. In 1995, the United States Food and Drug Administration (FDA) approved the first clot-busting agent for ischemic stroke, called tissue plasminogen activator (tPA).

Shortly after its approval, researchers learned that early treatment with tPA, within four and a half hours, led to better health outcomes. “This idea changed stroke care systems,” says Sheth. “We had to identify people with strokes and get them to the hospital quickly.”

But for brain hemorrhages, Sheth says, “that paradigm never existed.”

Previous treatment for brain hemorrhage led to better results

Sheth’s recent publication is the result of a collaboration with the American Heart Association Stroke Registry, one of the largest stroke registries in the world. In the registry, his team identified people who had suffered a brain hemorrhage, who were taking blood thinners at the time of their hemorrhage, and who had received reversal blood thinners.

Then, for this cohort, they observed the delay between the arrival of patients in the emergency room and the delivery of treatment. “There was a big cast there,” Sheth says. “Some received the reversal agent quickly, while for others it was quite slow.”

Their analyzes found that those who were treated quickly with a reversal agent had the best outcomes. Patients treated within an hour of arriving at the emergency room had the greatest chance of survival. “There are popular phrases in neurology such as ‘time is brain’ and ‘every minute counts,'” Sheth says. “These results are consistent with these sentences, but for cerebral hemorrhages they are verified for the first time.”

The team also found several factors significantly correlated with shorter wait times. For example, white patients faced significantly shorter wait times than black patients. “We not only have the opportunity to improve overall survival in brain hemorrhages, but also to alleviate health disparities,” Sheth says.

The study demonstrates that cerebral hemorrhages constitute an urgent emergency in which every minute counts. “Before, we didn’t know that time was important, so clinicians didn’t rush in with the same rush as they did with strokes,” Sheth says. “Now we can begin to lead quality improvement efforts to treat brain hemorrhages more quickly.”

Sheth’s team continues to work with the American Heart Association to conduct further analysis. They hope to learn more about the factors that explain why some patients wait longer for treatment, and also develop and roll out initiatives to help patients get the care they need more quickly.