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]

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]

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]

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]

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.

[allodwick]

A couple of important points.

Warfarin and Lovenox do not break up or dissolve clots. They prevenr them from getting started or from growing after they are started.

The New York Times has not been a good source of news about warfarin in the past. They have written about warfarin changing the viscosity of the blood. It does not do that. It slows the ability to form a clot.

When you slow the ability of the blood to clot, then by definition you increase the risk of bleeding.

The problem is that you don't exactly know the limits of how much to give. With warfarin, staying in your range gives the most protection from a stroke with the least risk of bleeding. But like everything else in life, there are no absolutes.

I use a lot of driving analogies. It is rather like driving with no speed limit signs posted. There are speed limits - you just don't know for sure what they are. However, you are still likely to get into trouble for violating the laws.

Mary, I wish I could comment on your mother's case but I have no experience with this sort of thing.

[Blanche]

You certainly didn't bore me. I obviously have a vested interest in information about strokes and anticoagulants. I have not known how to respond here, so I have been holding my own counsel. The information that you presented did help direct my thinking. Thank you for sharing your experiences with us. Hope are well and enjoying life now. You have bee missed.
Blanche

[Granbonny]

I was the old friend that asked Gisele to post on this thread.:) She has 564 posts on VR.Com..A wealth of infomation on what she went thru..2 years ago...We old-timers went thru it with her.......Posting and praying that she would come thru her ordeal..........Thank you for coming back and posting, Gisele. ...You are a great friend and e-mail buddy.:) ...Bonnie

[allodwick]

Gisele,

I applaud your courage. You have no idea how many pharmacy students I have discussed your experiences with.

I wonder if PM Sharon had failing kidneys and they didn't adjust his Lovenox dose downward for this and he was overdosed.

[Gisele]

You were all so much of a support team for me because I felt that you all were going through this every step of the way with me. Thank you. :)

I'll be honest though, I don't miss my Coumadin........and my Lovenox.........let's just say we didn't get along too well.

Guess I was just one of "those" patients who even though I followed the rules things just didn't work out. I wish eveyone here on the board good luck. There are so many new people here I just can't keep up! :)

[bvdr]

You are missed around here Gisele! Thanks for coming back in to visit. I hope all is going well with you. Sometimes I ponder the situation you were going through. If I remember right, you were totally off ACT while you awaited getting a biological valve. We were all anxiously awaiting with you and praying you would be fine. I also seem to remember that while you were in the hospital one of your family members posted that when they explanted your mechanical valve it was noted that some clotting had begun to develop. Do you remember how long you were off any anticoagulation therapy?

[Gisele]

Hmmm......Let me see..........I think I went off Coumadin in Boston with the subdural and after the heparin incident they decided I should not go back on it. I had to wait three months to get my heart surgery because they wanted to wait for my head to heal ???? Betty....I am not sure.....the reason..but I know I was at least three months with no Coumadin, no Lovenox, nothing......it might have been longer....wait..........closer to 4 mos.......so I guess I was lucky, huh? Especially with a mitral mechanical valve too.

Glad it is all behind me now. That was ever so scary.............how are you doing?????

[allodwick]

Even though it has been quite a while since you posted, Gisele, it does not appear that you have aged at all.

[Gisele]

OK, I'll get Ross to help me change it..........ross?????

[Marge]

The BBC reports that debate over whether Sharon got/is getting appropriate treatment is "front-page news in Sunday's Israeli press."
There are several articles today in Haaretz, one of the major Israeli papers. Haaretz English language site: http://www.haaretzdaily.com/hasen/pages/ShArtVty.jhtml?sw=martin+rabbai&itemNo=667331

The BBC interviewed its own expert, who said that it was "very bad medical management to use anti-coagulant drugs" in this case:

<<A senior UK-based cardiologist told the BBC News website the fundamental question concerns possible misdiagnosis after the prime minister suffered a first minor stroke on 18 December.
After that incident, doctors found that Mr Sharon had a birth defect, a patent foramen ovalis (PFO) or hole in the heart, which they planned to close with a catheter operation. Doctors said the hole was thought to have contributed to the minor stroke.
But, in the light of subsequent developments, the cardiologist believes it created a blinkered, over-rosy picture, which allowed Mr Sharon to keep up his punishing work schedule at a time of high political importance.
"A PFO is a condition that 20% of people suffer from, but it's extremely unlikely to cause a stroke in a man in his 70s," the cardiologist said.
"If it's going to affect you it'll happen when you're in your mid-30s, not in your 70s."
Doctors at the Hadassah insist Ariel Sharon has received the best care
Instead of the congenital defect, Mr Sharon's first minor stroke was, the cardiologist said, more likely to have been caused by obesity, lifestyle or the severe stress that he has been under, with Israel at a political turning point and his son Omri embroiled in a corruption scandal.
His doctors prescribed anti-coagulation medicine as he awaited catheterisation and Mr Sharon brushed off the crisis, refusing to take the month or more's rest that most doctors would have ordered.
The UK doctor says the blood-thinning treatment would alleviate his condition as diagnosed but could prove "catastrophic" in another scenario, if, for example, Mr Sharon had suffered an undetected haemorrhagic stroke, or "small bleed" in his brain.
"It is very bad medical management to use anti-coagulant drugs in a case like this, because in the event of a small bleed it will make matters much worse," he said.
Professor Martin Rabbai, a senior Israeli neurosurgeon agrees with this view, in quotes in Sunday's Haaretz newspaper.
The heart catheterisation was "not recommended," the paper quotes the doctor saying, since it had not been proven that the stroke was caused by a blood clot crossing the hole in Mr Sharon's heart.
"On the contrary, it is advisable not to touch it," for someone in Mr Sharon's condition, Professor Rabbai said.
However the hospital director, Mr Krumer, defended all the treatments administered to Mr Sharon.
"These decisions were taken after consultation among senior staff at Hadassah hospital and with world-renowned specialists outside Israel," he said.
One neurologist told Haaretz he believed Mr Sharon was a victim of "VIP syndrome" - over-treatment given to prominent figures that is unnecessary, or even damaging, to their health.
Doctors say that, even if he survives, the condition is likely to have left him severely impaired physical and mentally.>> http://news.bbc.co.uk/2/hi/middle_east/4592488.stm

[hensylee]

Isn't it interesting that everybody in VR questioned his treatment!

[allodwick]

I wondered about the VIP aspect, too. I remembered a case from when I was in college. The son of a prominent person in the medical school had an attack of appendicitis. The word was that the heads of all of the departments were called in. They operated on him and he died. Supposedly a case of clashing egos not allowing anyone to do what they thought was right.

My sister is a college history professor. When she goes to her university's medical center she refuses to be seen by anyone but the department head. I ask her if her department head is the best historian on the staff? It seems to me that department heads are the best politicians, not the best clinicians. I can't figure out why she would want to be treated by the best politician.

[lance]

Very well stated--gives pause for thought.

[Marty]

I agree that 1. Sharon very likely did not need to have his PFO closed. 2.He did not need to be put on enoxiparin. If he was not a VIP I think he would have been told to rest, and then re-evaluted later. VIP snyndrome? I think so!
I was a resident at Walter Reed in the 50's when Ike and a host of other VIP's were treated there. One of our internists in a moment of pique said if he ever became ill he would tear off his colonel eagles and all of his decorations and throw himself on the front steps and tell admissions he was a buck private!

[RCB]

You guys are so profound, it is scary!

[Mama2Rylan]

When reading some info about Sharon's stroke, it did seem to put alot of blame on the "blood-thinner"s (as they put it). I tried to read your posts first to see if it answerd my question I'm about to ask, but alot of this stuff is way over my head I'm afraid:o So my question is, what is Cloxane? That was the anti-coagulant that he was put on. Is it something new? All I have ever heard of is Coumadin (Warfarin) and Heperin...

[Lynlw]

I believe it's lovenox Lyn

[allodwick]

Lyn is right. Lovenox is the US name, some countries use the brand name Clexane and maybe even Cloxane. It is all enoxparin - a heparin derivative.