This quick post comes to you from the EMedHome weekly clinical pearl, which was forwarded along to me with a “Good stuff?” open-ended question.
The “good stuff” referred to a series of articles discussing the “CTA spot sign”, referring to a radiologic marker of ongoing extravasation of blood following an intracranial hemorrhage. As logically follows, ongoing bleeding into a closed space has been associated with relatively increased hematoma growth and poorer clinical outcomes.
However, the post also highlighted – more in an informational sense – an article highlighting potential use of prothrombin concentrate complexes for treatment of bleeding, regardless of anticoagulation status. We are all obviously familiar with their use in warfarin-related and factor Xa-associated ICH, but this article endeavors to promote a hypothesis for PCC use in the presence of any ICH with ongoing radiologically apparent bleeding.
The evidence produced to support their hypothesis? A retrospective 8 patient cohort of patients with ICH and CTA spot sign, half of whom received PCCs and half who did not. Given the obvious limitations regarding this level of evidence, along with problems of face validity, there is no reason to revisit their results. The EMedHome pearl seemed to suggest we ought to be aware of this therapy in case a specialist consultant requested it. Now, you are aware – expensive, unproven, and not indicated without a substantially greater level of evidence to support its use.
“Role of prothrombin complex concentrate (PCC) in Acute Intracerebral Hemorrhage with Positive CTA spot sign: An institutional experience at a regional and state designated stroke center”
https://www.ncbi.nlm.nih.gov/pubmed/27915393
Dr. Radecki:
As the editor of EMedHome.com and the author of the clinical pearl to which you refer, I take exception to the way the pearl is presented in your post. As stated at the start of the pearl, the reason we distributed this pear is to make the Emergency Physician familiar with the Spot Sign and its significance, given the increasing role of CTA in emergency neuroimaging. Your post implies that EMedHome supports the use of PCC in this case, which is not accurate. We felt it was important to bring up the small study because consultants often over-react to new studies, even when they are under powered. In such an instance, the EP can, at least, be familiar with the topic.
Certainly a clarification in your post would be appreciated.
Thank you,
Rick Nunez, MD
EMedHome
Hi Rick.
I appreciate the feedback, but it’s not clear to me what sort of clarification is necessary. The deficiency in the pearl distributed, if any, in my opinion is simply not clearly addressing the PCC study as grossly inadequate to support the practice. It was not at all clear to the clinician forwarding along the pearl the study presented was barely more than the plural of anecdote. The CTA spot sign information, on the other hand, is quite useful education.
Best,
Ryan
Hey Ryan:
Thanks for the prompt reply. The clinical pearl does mention it is a small study and certainly it goes without saying that no clinician should change practice based on a single study, and a very small one at that. For sake of brevity, I did not think it would be valuable to go into the actual numbers. Thank you for saying that the Spot Sign info is useful.
I think the major concern is the headline on the tweet which, when put together with the first line of the tweet link, communicates a negative critique of EMedHome. At least one of your followers would seem to agree (the first reply is a drop the mic). Maybe a clarification on your twitter feed that the Spot Sign is valuable info?
Hey, again, thanks for the reply and willing to engage in a constructive manner – impressive!
Rick