On Sharon’s cerebral hemorrhage

I’ve also given it a bit of thought. Certainly a hemorrhagic CVA is always a potential complication of anticoagulation. But I assume Sharon’s PT, INR, etc were also being monitored per protocol. One of the most common reasons for a hemorrhagic CVA is hypertension, and I haven’t seen anything yet written as to what his BP status was. If the inciting event was a hypertensive CVA, of course any degree of anticoagulation would make it worse. But I’m not sure that therapeutic anticoagulation, without dangerously high PT or INR values, would incite a “massive stroke” in and of itself. But I’m a gynecologist and would certainly defer to colleagues with a different perspective.

Sharon was being anticoagulated because of a suspected paradoxical embolus through a patent foramen ovale. That was thought to be the cause of his TIA, and the procedure planned was presumably a percutaneous PFO closure.
The management of cryptogenic stroke and PFO remains quite unsettled. A good review appeared in the NEJM recently.
The likelihood of this diagnosis in a 77yo male is debatable, though of course I don’t have all (or any) of the facts.
I disagree with db: anticoagulants are not the standard of care for thrombotic strokes, only thromboembolic ones.

You are talking 1975 when you speak of Coumadin anticoagulation for patients after ischemic stroke. Only for cardioembolic strokes or in patients with established atrial fibrillation would Coumadin anticoagulation make sense today. You may review the Cochrane report from 2001 (there is no new data to change their conclusion that aspirin reduces the risk of recurrent stroke by 15-20% and that there is no current evidence that Coumadin at any dose gives better results). The International ESPRIT study is still ongoing and may provide better insight into this situation.
I am a neurologist who sees only patients under 25 years old. My stroke colleagues say a. Many people have patent foramen ovale- perhaps 20%. They would be very dubious that a PFO explained a stroke in a 77 yo man who is 100 pounds overweight. They would treat such a person with aspirin and weight reduction.
b. The fact that the patient was still bleeding after the first craniotomy and required immediate reoperation strongly argues for excessive anticoagulation.
c. They would not permit a third operation on a relative in Sharon’s situation – it’s futile

Israeli neurologists are good. The problem is that political big shots are overtreated, not just in Israel. We should always be asked, is this what you would want for yourself, your parent or your child?

Cochrane reference:

Agra, A, et al. Oral anticoagulants versus antiplatelet therapy for preventing further vascular events after transient ischaemic attack or minor stroke of presumed arterial origin. Cochrane Database Syst Rev. 2001;(4):CD001342.

Bob Snodgrass

clexane= enoxaparin[low molecular weight heparin], according to medic,co.il : prophylactic in moderate risk[gen.surg]20 mg. x 1/d for 7-10 d. or until ambulatory. Prophy. in high risk [orth.surg]40 mg. x 1/d. for three weeks. Deep vein thromb./unstable angina/non Q Wave MI: 1 mg/kg. body weight every 12 hours[ very high dosages in my humble opinion].

my dad suffered from the same thing march 6th he was paralyzed onthe left side the drs did nothing except blood pressure meds but we had to turn off the machines 6 days later and he passed