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Chapter 11. Neuro-hematology

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Which of these target-specific oral anticoagulants, when compared to warfarin, is associated with a lower rate of stroke recurrence, lower rate of major bleeding complications, and lower rate of central nervous system (CNS) bleeding?

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A. Dabigatran 150 mg twice daily

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B. Rivaroxaban 20 mg daily

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C. Rivaroxaban 15 mg daily

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D. Apixaban 5 mg twice daily

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E. Aspirin 325 mg daily

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D. In the ARISTOTLE trial, a total of 18,201 patients with atrial fibrillation (AF) were randomized to apixaban 5 mg twice daily versus warfarin (goal international normalized ratio [INR] between 2 and 3). The results demonstrated a significant decrease in the primary outcome, which was stroke or systemic embolism, and in the number of strokes (hazard ratio [HR], 0.79; 95% CI, 0.66-0.95; P = .01). Major bleeding complications (HR, 0.89; 95% CI, 0.35-0.75), including a noticeable reduction in intracranial hemorrhage (HR, 0.42; 95% CI, 0.30-0.58), were also significantly reduced. WASID trial results, which looked at warfarin versus aspirin for treatment of symptomatic intracranial arterial stenosis, showed that warfarin did not have any benefits over aspirin in lowering stroke/vascular death risk while increasing the adverse events. In this trial, patients who were on aspirin had lower rates of major bleeding, myocardial infarction, and sudden death. In the RE-LY trial of 18,234 patients with AF, dabigatran at the twice-daily dose of 150 mg was associated with lower rates of stroke but similar rates of major bleeding compared to warfarin. The rate of stroke prevention in the dabigatran 110-mg arm was equivalent to that in the warfarin arm, but this dose had lower rates of bleeding complications. In the ROCKET-AF trial, 142,64 patients were randomized to either rivaroxaban 20 mg daily (15 mg/d if Cr clearance was 30-49 mm/mL) or warfarin (INR goal 2-3). Results demonstrated an equivalent rate of stroke and major bleeding, with a lower rate of intracranial hemorrhage.

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What is the recommended dose of protamine sulfate 90 minutes after heparin drip has been discontinued?

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A. 1 mg protamine/100 U unfractionated heparin

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B. 0.5 mg protamine/100 U unfractionated heparin

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C. 20 mg of protamine

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D. The dose of protamine depends on patient’s weight

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E. There is no need for reversal at 60 to 120 minutes since the half-life of IV heparin is 30 to 45 minutes

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A. Per the 2015 Neurocritical Care Society (NCS) guidelines for the reversal of antithrombotics after intracranial hemorrhage (ICH), the dose of protamine is ...

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