What is the preferred choice between Plavix (clopidogrel) and Eliquis (apixaban) for managing intraventricular hemorrhage (IVH) in the context of a cardiovascular accident (CVA)?

Neither Plavix nor Eliquis is Recommended for Intraventricular Hemorrhage CVA

Neither clopidogrel (Plavix) nor apixaban (Eliquis) should be used in patients with intraventricular hemorrhage (IVH) as both medications significantly increase bleeding risk and are contraindicated in active intracranial bleeding.

Understanding Intraventricular Hemorrhage

Intraventricular hemorrhage is a severe form of intracranial bleeding where blood enters the ventricular system of the brain. Management focuses on:

• Controlling intracranial pressure through external ventricular drainage rather than anticoagulation or antiplatelet therapy 1
• Treating hydrocephalus, which occurs in approximately 45% of ICH patients 2
• Reducing mortality, which increases from 20% without IVH to 51% with IVH when associated with intracerebral hemorrhage 2

Contraindication of Antiplatelet and Anticoagulant Medications

Clopidogrel (Plavix)

• Clopidogrel is explicitly contraindicated in patients with active pathological bleeding, including intracranial hemorrhage 2
• Studies show reduced platelet activity (as caused by clopidogrel) is associated with more severe intraventricular hemorrhage 3
• Prasugrel, another thienopyridine like clopidogrel, is specifically not recommended in patients with a history of TIA or stroke due to increased risk of fatal and intracranial bleeding 2

Apixaban (Eliquis)

• Direct oral anticoagulants like apixaban significantly increase the risk of hemorrhage expansion in active intracranial bleeding 4
• While apixaban has lower overall bleeding risk compared to warfarin, it still poses unacceptable risk in active intracranial hemorrhage 4
• Apixaban is associated with intracranial hemorrhage risk, though at lower rates than warfarin, but should not be used in active bleeding 2

Current Management Recommendations for IVH

The American Heart Association/American Stroke Association guidelines recommend:

• Ventricular drainage as treatment for hydrocephalus in IVH patients, especially those with decreased level of consciousness (Class IIa; Level of Evidence B) 2
• ICP monitoring and treatment for patients with GCS score ≤8, clinical evidence of transtentorial herniation, significant IVH, or hydrocephalus 2
• Maintaining cerebral perfusion pressure of 50-70 mmHg depending on cerebral autoregulation status 2

Potential Interventions for IVH

In selected cases where clot removal is necessary:

• Intraventricular fibrinolytic therapy with tissue plasminogen activator (tPA) or urokinase may be considered to accelerate blood clearance 2
• Meta-analysis of studies showed mortality decrease from 47% to 23% with intraventricular fibrinolysis compared to ventricular catheter alone 2
• Surgical evacuation may be considered in severe cases, though randomized trials have not demonstrated clear benefit 2

When to Resume Antithrombotic Therapy

If a patient has an indication for antiplatelet or anticoagulant therapy (such as atrial fibrillation or coronary stents):

• Antiplatelet or anticoagulant therapy should be discontinued during acute IVH management 2
• Resumption should only be considered after complete resolution of the hemorrhage and stabilization of the patient 2
• When restarting is necessary, the American College of Cardiology suggests carefully weighing thrombotic risk against bleeding risk 2

Conclusion

For intraventricular hemorrhage, the management focus should be on:

• External ventricular drainage to control intracranial pressure 2, 1
• Avoiding all antiplatelet and anticoagulant medications during the acute phase 2
• Considering intraventricular fibrinolytic therapy in selected cases 2

Neither Plavix nor Eliquis has a role in the acute management of intraventricular hemorrhage.