Questions about Israeli PM Sharon's stroke

[Marge]

CNN said that Sharon had been placed on "blood-thinning medications" after an earlier stroke caused by bloot clot. The latest, massive stroke was caused by a cerebral hemorrhage, bleeding in the brain, which can "cause a blood clot." CNN then goes on to say that the "blood-thinning" medications "may have contributed" to the hemorrhage, and therefore to the stroke.
What's going on here? I assume he was on coumadin on some similar anti-coagulant of that sort.
Since anti-coagulants are supposed to prevent clots & strokes, how could they "contribute" to a clot and a stroke?
I'm really confused!
Of course Sharon just looked like a stroke or heart attack waiting to happen. Accounts I have read of his eating habits prior to the first stroke are mind-boggling. It's amazing to me that his BP & cholesterol were said to be "normal."

Here's the CNN story:

<<Doctors: Sharon stroke caused by bleeding in the brain

Wednesday, January 4, 2006; Posted: 10:17 p.m. EST (03:17 GMT)
(CNN) -- Israeli Prime Minister Ariel Sharon suffered massive bleeding in his brain from a type of stroke called a cerebral hemorrhage, his doctors said Wednesday.

A cerebral hemorrhage happens when small blood vessels bleed in the brain and cause a blood clot. This causes pressure on the brain, eventually killing normal brain cells, which can cause permanent disability or death.

It was Sharon's second brain attack in less than three weeks. After the first, he was put on blood-thinning medications which may have contributed to the hemorrhage.

Having a previous stroke, having high blood pressure or smoking can increase a person's chances of having a stroke.

Sharon was taken by ambulance Wednesday to the hospital after complaining of chest pain and weakness, said Ra'anan Gissin, his senior adviser. He was conscious when he arrived at the hospital, Gissin said.

"After that, apparently there was some worsening of the condition," he said.

Doctors sedated Sharon and performed an MRI scan, Gissin said. They diagnosed a cerebral hemorrhage and he was taken into surgery to remove the blood, a procedure which was expected to take several hours.

Sharon had suffered a smaller stroke caused by a blood clot on December 18. He never lost consciousness during that incident, according to Tamir Ben Hur, head of neurology at Hadassah Ein Kerem Hospital.

"There was no slurring. He was not confused. He suffered from a certain difficulty in speaking. A small blood clot briefly blocked a blood vessel in his brain," the doctor said.

Ben Hur said the clot was dissolved by medication, adding, "Our comprehensive investigation has shown definitely that the stroke will not leave any damage or traces." (Full story)

It was during treatment for the first stroke that doctors discovered he had a small hole in his heart that could have led to the formation of the clot that may have caused the mild stroke.

The second massive stroke came hours before scheduled surgery to repair the hole in his heart.

Doctors had ordered the overweight prime minister to go on a diet. Sharon's doctors said earlier this week that he weighed 260 pounds (118 kilograms) at the time of the stroke, and had lost more than 6 pounds (3 kilograms) since then.

Sharon's doctors said then that his blood pressure and cholesterol levels were normal, though he has an under-active thyroid gland -- common in overweight people. >>

 

[Nancy]

I don't know if this will shed any light, but Joe has had several infarctions recently. Nothing in his brain. They hit his spleen and his eye unfortunately.

He is on a very high INR 3.5-4.0 to try to prevent these.

After the eye stroke (artery occlusion) I asked his doctors about adding Plavix to his medications to prevent further stroke formation, and possibly avoid a massive brain stroke.

The answer I got was that "Yes, it could possibly help to prevent a 'clotting' stroke", but it would add large vulnerability for a "bleeding" stroke.

So Plavix has not been added.

I thought about the wisdom of that decision when I read about Sharon's bleeding stroke.

 

[Kate]

I'm not a medical person, so I may not have this exactly correct, but my understanding is that strokes can be caused by blod clots or by bleeding in the brain. Unfortunately, while Coumadin helps prevent the first, it can increase the chances of the second. Let's hope his surgery was a success and he'll be out of the woods soon. Kate

 

[catwoman]

And has anyone seen an exact explanation of what that "hole" in his heart is/was?
ASD? VSD? Something else???

 

[Lynlw]

I believe it is a PFO patent formen ovale (spelling), which is a hole between the atriums in fetuses. normally when they baby is born it closes, but in many people it doesn't, Lyn

 

[Marty]

Stroke and hole in heart

Stroke and hole in heart

I believe it is a PFO patent formen ovale (spelling), which is a hole between the atriums in fetuses. normally when they baby is born it closes, but in many people it doesn't, Lyn

The way I read the news, Sharon, had a minor stroke due to a thrombus, so called ischemic stroke or TIA. They also found a small defect in the heart septum that separates the right and left sides.(either patent foramen ovale or persistent ventricular septal defect) So Sharon gets a little clot in a deep leg vein which breaks loose and travels to the right side of his heart but instead of going to his lung ( pulmonary embolism)as it should ,it goes through the septal defect into the left ventricle and out the aorta into the carotid artery in the neck and then into his brain.( Teddy Brushci linebacker for the New England Patriots had this same thing recently and had his heart fixed and is now playing again)
It looks like Sharon was anticoagulated and that they intended to fix his heart soon. However he is older and I wonder what his INR measured at the time of this second severe hemorrhagic stroke. I have always been a little leery about anticoagulating stroke patients and have seen this scenario before, particularly in older patients.

 

[Mary]

The way I read the news, Sharon, had a minor stroke due to a thrombus, so called ischemic stroke or TIA. They also found a small defect in the heart septum that separates the right and left sides.(either patent foramen ovale or persistent ventricular septal defect) So Sharon gets a little clot in a deep leg vein which breaks loose and travels to the right side of his heart but instead of going to his lung ( pulmonary embolism)as it should ,it goes through the septal defect into the left ventricle and out the aorta into the carotid artery in the neck and then into his brain.( Teddy Brushci linebacker for the New England Patriots had this same thing recently and had his heart fixed and is now playing again)
It looks like Sharon was anticoagulated and that they intended to fix his heart soon. However he is older and I wonder what his INR measured at the time of this second severe hemorrhagic stroke. I have always been a little leery about anticoagulating stroke patients and have seen this scenario before, particularly in older patients.

Well, I'm confused Marty. After I read your answer, and reread the original posting, it struck me that this sounds similar to what happened to my mother about 11 years ago. She had a pretty significant TIA; scans revealed the clots were originating from the cerebellum and so she was started on coumadin. I asked about this once before on the Forum but never got anyone to answer my question.
My question is do they anticoagulate to dissolve or to prevent any clots, while knowing at the same time there's a signficant risk of brain hemorrage? Wouldn't the range have to be very narrow to accomplish this?
Am I understanding this correctly?

 

[Marge]

All I can say is it is very scary.

I admit to a personal stake in this, which is the reason I posted the article and the query in the 1st place. I was on coumadin after my valve repair. I had never had a-fib or a-flutter except for one very brief episode of a-fib shortly after surgery; so everybody (surgeon & cardio) said I wouldn't have to continue on coumadin. So I was taken off after three months.

Then, this summer, I was diagnosed as having a-flutter and my cardio recommended going back on it, "to avoid risk of a stroke."

So, after thinking about it a lot, and because I am so not interested in having a debilitating stroke, I am now taking coumadin again.

Although I of course knew the potential for bleeding from taking coumadin, the thought of a stroke actually caused by bleeding (in the brain) didn't occur to me; and that possibility was not mentioned by my cardio -- he just said coumadin cuts down on the stroke risk for people with a-flutter or a-fib.

I'd be interested in knowing the risk of a stroke caused by bleeding associated with taking coumadin -- as compared to the risk of having a stroke if you decide not to take coumadin. Is there any easily accessible literature on this?

 

[Marty]

To Marge and Mary

To Marge and Mary

These are good questions you ask. I really don't know the answer if there is one.I do know they will not anticoagulate a stroke patient who is bleeding or who has a condition that might bleed. They evaluate this by CT and MRI studies. I think the best waay to get an authoritative answer would be to ask a stroke specialist- a neurologist, or an interventional neuroradiologist. My little clinic does not have either of these specialists but I wil ask around the hospital next week. If I learn anything definitive I will post it here.

 

[Cris N]

If you think about one of the warnings with warfarin... be careful about blows to the head - they can cause bleeding in the brain. And since the skull has very little extra space, unlike an arm or a leg, when the bleeding occurs it puts more pressure on the brain with the possibility of causing damage. Who knows, maybe Sharon bumped his head while experiencing chest pain.

Also, my understanding about clots is that they use tPA (Tissue plasminogen activator) to dissolve a clot (must be administered within a couple of hours) and warfarin can help to prevent an existing clot from getting bigger.

Cris

 

[Sherry]

I'll have to admit, this whole Sharon business has got me a little paranoid. I'm on both coumadin and plavix (for visual disturbances). I think I'm going to broach this again with my doctor. Yikes...

 

[Marge]

Another article on "blood thinners" (the media keep using that term instead of anti-coagulants) in the context of Sharon's stroke. This one's from the New York Times.
I wonder what caused his cerebral hemorrhage. There's been nothing about any blows to the head. The article says you are more likely to have one if you have high blood pressure; but all the stories I read or heard after his 1st stroke said he had "normal" BP.

<<January 5, 2006
Blood Thinners a Danger in Sharon's Treatment

By ELISABETH ROSENTHAL International Herald Tribune
The huge stroke suffered by Prime Minister Ariel Sharon of Israel, caused by uncontrolled bleeding into the brain, will probably be devastating and nearly impossible to treat because Mr. Sharon has been on blood thinners.

Although Mr. Sharon, 77, underwent surgery to relieve pressure caused by the blood pouring into his skull and is now being maintained in a state of deep anesthesia, these are desperate moves with uncertain benefit, neurologists said.

Hemorrhages in the brain while on blood thinners, "are usually devastating events," said Matthew Fink, chief of the Division of Stroke and Critical Care at the New York-Presbyterian Weill-Cornell Medical Center. "This sounds really terrible."

Statistically, the likelihood of death is greater than 80 percent, he said.

Before operating, doctors gave Mr. Sharon a drug to counteract the effects of the blood thinner he was taking. But even with his clotting ability so restored, it was unclear if surgery could save him because brain tissue dies in minutes when it is injured.

"They are trying to save his life with surgery but this is an extremely hazardous procedure," Dr. Fink said. "The goal is to save his life, but there is not much evidence that it will preserve neurological function."

Although surgeons announced today that they had stopped the bleeding after eight hours in the operating room, it could take days to see how much mental capacity Mr. Sharon recovers if he lives, experts said. He is now being maintained in a state of deep anesthesia, to attempt to rest the brain tissue that has survived the trauma.

Lalit Kalra, professor of stroke medicine at Kings College London, said: "We are now beyond areas of standard practice - things like repeated surgery to relieve pressure and inducing a deep coma - there are no studies.

"The outlook is grim, but the brain is a very strange tissue and surprises you sometimes."

Mr. Sharon was placed on the blood-thinning medicines in the last two weeks to treat the smaller stroke he suffered Dec. 18. In many respects his latest stroke was a medical complication of his earlier treatment.

Strokes occur when brain tissue suffocates because its normal blood and oxygen supply is cut off. There are two major categories of stroke, corresponding to the two underlying causes for the disruption of blood flow to the brain: Blood clots and hemorrhages into the brain.

In the first type of stroke, blood clots that form in other parts of the body, generally the heart, are carried along by the bloodstream and lodge in a blood vessel leading to a portion of the brain, depriving it of oxygen. In the second type of stroke, a blood vessel in the brain bursts - most commonly from high blood pressure - and the blood that pours out suffocates surrounding brain tissue.

Last month, doctors treating Mr. Sharon concluded that his stroke in December fell into the first category, since it was discovered that he had a small, previously undiagnosed hole between two chambers of his heart. Such holes can leave patients vulnerable to clot formation. Mr. Sharon was scheduled to have the hole repaired today. In the meantime, doctors placed Mr. Sharon on blood thinners, also known as anticoagulants, to prevent clots from forming.

Such medicines carry serious risks, leaving patients vulnerable to a wide range of bleeding complications, including severe bleeding within the brain. "This is a known side effect and a tragedy we all dread," Dr. Kalra said.

The medicines are also difficult to take and monitor because their thinning effects vary significantly from patient to patient, requiring frequent blood tests to detect excessive bleeding tendencies.

The decision to treat the hole in Mr. Sharon's heart - with all the attendant risks of blood thinners - surprised many neurologists, since recent studies have concluded that such holes are not likely to cause strokes in the elderly.

As many as a quarter of adults have such holes and the vast majority never cause trouble, neurologists said. >> http://www.nytimes.com/2006/01/05/international/middleeast/05cnd-bleed.html?pagewanted=print

 

[hensylee]

I am watching this thread very carefully. I have heard all the news and read what's here. My brother is on coumadin to prevent strokes. This is scary.

 

[Georgia]

This is interesting:

http://www.msnbc.msn.com/id/10723849/from/RS.4/

It would seem that if 85% of strokes are embolitic, then the use of anticoagulants would be indicated.

 

[Marge]

<< It would seem that if 85% of strokes are embolitic, then the use of anticoagulants would be indicated.>>

Yeah. Seems like life always involves playing the odds, doesn't it?

 

[perkicar]

I heard on this evening's news that he was "breathing on his own" which could mean a) he's on the vent but overbreathing the settings and initiating his own breaths or b) he's off the vent (which I would find pretty unusual!). God be with him as he fights to recover from this. He's got a hard road ahead of him.

 

[Mary]

In my mother's case (if I remember this correctly) due to her advancing age, there was an area in the brain that was gradually deteriorating. Blood was very slowly seeping from one small area through the tissue walls into another, but the bleeding eventually clotted. The doctor wanted her on coumadin so that the blood passed through without the clotting. They knew she would likely have some TIA's, but it was judged to be better than throwing a massive clot in the brain stem region.

 

[LLJ]

Ok my knowledge is not that of a physician,but working for so many years with stroke patients as a PT I will give you a oversimplified version of what I understand: As has been stated: strokes can be caused by either bleeds or emboli. To break an emboli one is given blood thinners.From my understanding, when a stroke occurs a CAT scan is done. The physicans play a balancing game to hope it is "simply" am embolitic event not carrying the possiblity of a "bleed out" Sharon did not look like he was in the best of shape prior to this event and there may also be many other contributing factors which we will never know about.(Stress,obesity.diabetes,smoking...?)
Clots can form on mechanical valves and with A fib. Coumadin will not cause a stroke (I believe) unless there is a predisopistion to venous wall weakening. Please talk to your doctors or health care professionals about your concerns. That is what they're paid for. It is your right and responsibilty to be informed.
Laura

 

[Gisele]

My 2Cents from my subdural and stroke experience...

My 2Cents from my subdural and stroke experience...

An old friend asked me to stop on by the board and speak of my experience of what I had gone through so I will try to be brief and maybe shed some light that there are no guarantees in life with any drug. You can just follow the drug instructions and hope that when lightning strikes that it misses you.

#1-Subdural--too much partying on vacation--very high INR-treated by monitoring in patient stay/going off Coumadin (yes very risky with mechanical valve, but then so isn't bleeding in the brain-take your pick).

#2-Subdural-INR in range-One of my many annoying migraine headaches that I suffer from that normally could last for anywhere up to 5 weeks. This one felt a bit different so after about I think 2 weeks I went to ER. Much larger bleed which I have to say was the most painful thing I have ever gone through. Rushed to Boston-surgery to drain the blood from brain. Vit K given in local ER and in Boston ER. Had a stroke when I came out of surgery. This affected my left foot. See, lots of Vit K---no protection on my valve with Heperin....well .....went home within one week. Two days later local cardio admitted me to local hospital for heparin to protect my valve..........

#3--Subdural again. Within 24 hrs of heparin that pain I said that I couldn't stand----it was back with a vengeance. There was no drug that I was given that would even take it away. This time for what ever reason (oh I was shipped back to Boston) they decided to observe this bleed and not drain it......I wasn't really paying much attention to what was going on.

So after all of that I went home......physical therapy..........neurological problems......due to the bleeds....memory...word recall.....my left foot is still numb/painful.......they don't know now if the MD moved it incorrectly during surgery or the surgeon on my discharge said he might have nicked my cortex(I think I might have needed that part of my brain) Anyhow, now it has been two years, and I am grateful that I am alive, although I have issues....then I think of those who are less fortunate than myself and I know that I have a lot to be thankful for.

Hope I didn't bore anyone. OH yeah, I had my mitral valve of 21 years removed because I never went back on Coumadin and had a tissue valve put in. I have had it now for two years. The down side is that I will need to have it eventually replaced.

Sorry for going on so long............

 

[Marty]

Lovenox the culprit?

Lovenox the culprit?

Sharon was on Lovenox(enoxiparin) not warfarin. It may not have caused his bleed but undoubtedly made it more severe. Do Lovenox and warfarin -so called blood thinners increase risk of hemorrhagic stroke? Yes, but nobody knows what that risk is for sure. We know that it is greater for older people than young folks. Younger people recover better than older people if they do stroke.My neurologist-stroke guy says Sharon was given the proper treatment after his littlle ischemic stroke. His bleed was made worse by Lovenox and may even have been caused by it.Sharon has almost no chance for survival and if he does he may be a vegetable.