Stroke hemorrhagic conversion

The risk of conversion is always there. The decision to be made is whether the risk outweighs the benefits.

In my experience, far more people are helped with anticoagulation than are harmed by a conversion. The actual percentage of conversions is relatively small, and is a far greater risk when given tPa than with traditional anticoagulants (heparin, etc). The risk of conversion is why there is established windows for tPa.

A great percentage of people who come in with ischemic stroke are found to have newly diagnosed afib on admission. The risk of throwing a secondary clot in that population far outweighs the risk for hemorrhagic conversion.

I think to say that people shouldn't get aspirin or heparin because of conversion risk is a very narrow and limiting statement, and should be evaluated on a case-by-case basis after all the risk/reward analysis has been done.

Just my thoughts on the matter

In this case no a fib was detected on the EKG or telemetry. To say it's narrow by my reading is incorrect. 10-40% of all ischemic infarcts have transformation to bleeding. In my view without increased NIH scores (hourly) holding the Plavix (seriously?), the Lovenox and the Aspirin is prudent. If someone has any idea why after all our training there is no established standard....please let me know.

This is an informative thread, thank you....I had the thinking, ok for TPA and anti coagulation for neg CT scan....now I question, and I'm very experienced...thanks all

In this case no a fib was detected on the EKG or telemetry. To say it's narrow by my reading is incorrect. 10-40% of all ischemic infarcts have transformation to bleeding. In my view without increased NIH scores (hourly) holding the Plavix (seriously?), the Lovenox and the Aspirin is prudent. If someone has any idea why after all our training there is no established standard....please let me know.

There are established standards, and they involve administration of aspirin and antithrombotics.

Aspirin and heparin/SCD's administration by the end of hospital day two are two of the joint commission core measures, unless contraindicated in which case a note must be made in the chart by the physician. I worked at a comprehensive stroke center in the neuro ICU for years.

Like the previous poster said, it is a core measure for stroke patients to be on ASA, antithrombotic and a statin by day 2 of admission.

There is a risk of conversion, like you said, but it is small. I also work in a stroke center, and I've only seen it once.

This isn't research based, just my opinion, but I would say the risk of the pt. throwing a secondary clot would be greater, particularly if they are in a-fib and/or immobilized d/t the stroke.

In this case no a fib was detected on the EKG or telemetry. To say it's narrow by my reading is incorrect. 10-40% of all ischemic infarcts have transformation to bleeding. In my view without increased NIH scores (hourly) holding the Plavix (seriously?), the Lovenox and the Aspirin is prudent. If someone has any idea why after all our training there is no established standard....please let me know.

You are talking about hourly NIHs and intensivists. Our tpas go to ICU and the rest come to my floor. You are making me wonder if you are mixing details up. If a patient has received tpa, holding other anticoagulation may be appropriate. If the patient has not received tpa, you need to give it. I admit my experience is limited, but in the last year of being on the "stroke floor", I have yet to see an ischemic convert. We are also gold plus certification recipients from AHA for the last 4 years in a row, so we take guidelines pretty seriously, and people come to us bypassing other places just for stroke care.

For us, we do q12h NIH (for non-tpa), q4h or q6h detailed neuro checks, CT and NIH on arrival, MRI the next day, and follow up CTs or MRIs as needed. Anticoagulants and antithrombotics are started immediately after admission to the floor based on standard admin times. Full cardiology work up happens the first day shift after admission.

Not a day goes by that we don't have stroke patients. This is why I'm a bit surprised by the stats you quote. I understand it's anecdote, but I've never seen a conversion happen. I concede it's possible, of course, I just haven't seen it.

So if you have a PPM, you don't receive antiplatelet and anticoagulant?

You are talking about hourly NIHs and intensivists. Our tpas go to ICU and the rest come to my floor. You are making me wonder if you are mixing details up. If a patient has received tpa, holding other anticoagulation may be appropriate. If the patient has not received tpa, you need to give it. I admit my experience is limited, but in the last year of being on the "stroke floor", I have yet to see an ischemic convert. We are also gold plus certification recipients from AHA for the last 4 years in a row, so we take guidelines pretty seriously, and people come to us bypassing other places just for stroke care.

For us, we do q12h NIH (for non-tpa), q4h or q6h detailed neuro checks, CT and NIH on arrival, MRI the next day, and follow up CTs or MRIs as needed. Anticoagulants and antithrombotics are started immediately after admission to the floor based on standard admin times. Full cardiology work up happens the first day shift after admission.

Not a day goes by that we don't have stroke patients. This is why I'm a bit surprised by the stats you quote. I understand it's anecdote, but I've never seen a conversion happen. I concede it's possible, of course, I just haven't seen it.

I agree - I strongly suspect that the OP's statistics mixed complications (including hemorrhage) of the tPa and non-tPa populations.

The risk of adverse bleeding following tPa administration is well-known and is reflected in the tightly controlled protocols governing its administration. Without question, anti-coagulants and anti-platelet agents should be held for a period of time following tPa.

Regardless of what one individual believes to be correct, each hospital has a protocol for CVA, NSTEMI, DVT prophylaxis,CAUTI, VAP, etc. those protocols are to be followed.

Some hospitals are stroke certified and don't have MRI capabilities after certain hours or on weekends, so antiplatelet and anticoagulant therapy would be withheld and that could be detrimental to the patient.

i agree after tPA one would not immediately start those therapies, however if not tPA'd my hospital normally starts ASA and Lovenox (if not contraindicated) immediately after CT results.

This really is a good discussion and I believe will have many stroke certified nurses rushing to research EBP.

Hemorrhagic conversion/transformation is actually pretty common after ischemic stroke, with or without rtPA. The use of heparin or LMWH is not actually recommended, but rather it's tolerated by stroke core measures.

Based on the pathophysiology of an ischemic stroke, some degree of resulting hemorrhage is essentially guaranteed. Unlike other tissues in the body that become more solid when they infarct, brain tissues become less solid and essentially melt, this causes vessels in the infarcted region to leak.

Whether or not that leak is detectable or causes clinically significant symptoms is what varies. Studies that use more sensitive measurements (imaging) and look at a longer period of time show the incidence of hemorrhagic transformation to be as much as 40%. Studies that only look at the percentage of patients that have a significant change in NIH score in a shorter time period show lower rates, but still not particularly rare, ranging between 2% and 6% in non-rtPA treated patients, and 6-20% in patients who received rtPA. So it's pretty unlikely that a nurse caring for stroke patients have never had a patient with a hemorrhagic transformation, it more likely they just didn't realize it.

Core measures do recommend using aspirin which is supported by the evidence, although barely, the use of dual-anti-platelet therapy (aspirin and clopidogrel) has conflicting evidence. Heparin is actually specifically not recommended for this purpose.

The use of VTE prophylaxis in stroke patients is a core measure, but the guidance literature for that core measure is pretty clear that heparin and LMWH should not be the first choice for VTE prophylaxis in stroke patients. Ideally, ambulation is the prevention measure used and if that's not possible then SCD's would be the next choice. There was a lot of push-back from facilities about the difficulty of tracking SCD use and ambulation compared to heparin use, since medications are consistently charted, charting of SCD use is less consistent.

I've worked at a very good stroke center that as a rule never used heparin or LMWH for VTE prophylaxis in stroke patients and instead focused on how to ensure consistent charting of SCD use and ambulation to stay compliant. There are also facilities that rely on heparin use to stay compliant, essentially out of laziness.

Hemorrhagic conversion/transformation is actually pretty common after ischemic stroke, with or without rtPA. The use of heparin or LMWH is not actually recommended, but rather it's tolerated by stroke core measures.

Based on the pathophysiology of an ischemic stroke, some degree of resulting hemorrhage is essentially guaranteed. Unlike other tissues in the body that become more solid when they infarct, brain tissues become less solid and essentially melt, this causes vessels in the infarcted region to leak.

Whether or not that leak is detectable or causes clinically significant symptoms is what varies. Studies that use more sensitive measurements (imaging) and look at a longer period of time show the incidence of hemorrhagic transformation to be as much as 40%. Studies that only look at the percentage of patients that have a significant change in NIH score in a shorter time period show lower rates, but still not particularly rare, ranging between 2% and 6% in non-rtPA treated patients, and 6-20% in patients who received rtPA. So it's pretty unlikely that a nurse caring for stroke patients have never had a patient with a hemorrhagic transformation, it more likely they just didn't realize it.

Core measures do recommend using aspirin which is supported by the evidence, although barely, the use of dual-anti-platelet therapy (aspirin and clopidogrel) has conflicting evidence. Heparin is actually specifically not recommended for this purpose.

The use of VTE prophylaxis in stroke patients is a core measure, but the guidance literature for that core measure is pretty clear that heparin and LMWH should not be the first choice for VTE prophylaxis in stroke patients. Ideally, ambulation is the prevention measure used and if that's not possible then SCD's would be the next choice. There was a lot of push-back from facilities about the difficulty of tracking SCD use and ambulation compared to heparin use, since medications are consistently charted, charting of SCD use is less consistent.

I've worked at a very good stroke center that as a rule never used heparin or LMWH for VTE prophylaxis in stroke patients and instead focused on how to ensure consistent charting of SCD use and ambulation to stay compliant. There are also facilities that rely on heparin use to stay compliant, essentially out of laziness.

I appreciate this explanation. It does make sense. Thank you for it. I've actually been placed on a hospital-wide stroke committee starting in August, so I'm definitely looking at diving into EBP. This is a great place to start.

Thanks for the thoughtful replies. And no, I was not mismatching details. This was a CT negative (reported by patient) who did not receive tPA. I had a talk with one of our neuro docs on the unit yesterday where interestingly enough we had a tPA pt. They agreed with me and disagreed. If the CT and MRI were negative the Plavix and Lovenox should be given but one should wait until the evidence is in. Since I had no access to the computer or reports, they felt it was prudent to hold. It was interesting here in one study which was quoted by me that Lovenox had a higher incidence of conversion. I notified my agency (I travel to this hospital one day per week to help with a EMR training) and they wanted to share my experience with the hospital. I agreed...but after I leave in four weeks.

Again thanks for your educated replies. It has been helpful for me and I hope for others.