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• W4387249548 abstract "SESSION TITLE: Critical Care Case Report Posters 34 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Bevacizumab (BEV) is a monoclonal antibody that works as an angiogenesis inhibitor. The main adverse effects are hypertension, gastrointestinal perforation, arterial thromboembolic events, microangiopathy, and bleeding. Incidence of all grade hypertension (HTN) in patients receiving BEV is 23.6% and persistent HTN causes vascular stiffness making vessels more prone to changes in blood pressure (BP) and increased risk of hemorrhage. CASE PRESENTATION: A 69-year-old man with a history of cirrhosis secondary to alcohol use disorder and hepatitis C virus, recurrent hepatocellular carcinoma (on BEV and atezolizumab), cocaine use disorder (by snorting), HTN, active smoker, presented to the ER with projectile vomiting, fatigue and diarrhea for a day. He had a week of instability but no falls. He admitted using cocaine three days prior to admission. Physical exam: cranial nerves primarily intact except for tongue deviated to the right, no drifting, no nystagmus, no asterixis, strength 5/5 in the upper and lower extremity, nasolabial fold decreased on the left, gait with ataxia. Vitals stable except BP 166/96. EKG: NSR, left (L) axis deviation, LVH (old). CT head: acute right (R) basal ganglia hemorrhage without midline shift. MRI angiography: multiple multifocal (R midbrain, bilateral basal ganglia, R frontal, R & L temporal, R & L parietal) on a different stage of intraparenchymal and subarachnoid hemorrhage; no stenosis was noted in common bilateral carotid and internal carotid arteries. Labs: urine toxicology positive for cocaine. He was admitted to ICU for tight blood pressure control with nicardipine drip and close neurological monitoring. Per neurosurgery, he was non-surgical candidate. Same-day echo showed no abnormalities with LVEF of 55-60%, negative for shunts (bubble study). His symptoms improved after tight blood pressure, and he was transferred to the telemetry floor. DISCUSSION: Anti-VEGF therapy is associated with an increased risk of bleeding by disruption of endothelial cell integrity and increased vascular fragility. Risk of intracerebral hemorrhage (ICH) in solid tumor patients treated with anti-VEGF agents or BV is minimal or not significant. However, chronic hypertension with BV increases risk of cerebrovascular events. Cocaine-induced vasculopathy causes rapid increase in BP increasing risk of ICH. Although BP elevation after treatment with BV predicts response to therapy, in our patient BV induced HTN plus cocaine use synergistically lead to multiple intracranial hemorrhages, particularly when compounded by coagulopathy which in our case can be due to coagulopathy from hepatocellular cancer. CONCLUSIONS: Caution should be used when implementing bevacizumab therapy in patients with HTN and cocaine use, and appropriate patient teaching should be provided to mitigate adverse events. The question to consider is whether or not Bevacizumab should be given to a patient who uses cocaine? REFERENCE #1: Carden CP, Larkin JM, Rosenthal MA. What is the risk of intracranial bleeding during anti-VEGF therapy? Neuro Oncol. 2008 Aug;10(4):624-30. doi: 10.1215/15228517-2008-010. Epub 2008 Jun 6. PMID: 18539884; PMCID: PMC2666237 REFERENCE #2: Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M,Misra V, Grotta JC, Savitz SI. Intracerebral hemorrhage incocaine users. Stroke. 2010 Apr;41(4):680-4. doi:10.1161/STROKEAHA.109.573147. Epub 2010 Feb 25. PMID:20185779; PMCID: PMC3412877 REFERENCE #3: Nishimura T, Furihata M, Kubo H, Tani M, Agawa S, Setoyama R,Toyoda T. Intracranial hemorrhage in patients treated withbevacizumab: report of two cases. World J Gastroenterol. 2011Oct 21;17(39):4440-4. doi: 10.3748/wjg.v17.i39.4440. PMID:22110272; PMCID: PMC3218160 DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Vishal Reddy Bejugam No relevant relationships by Chen Chao No relevant relationships by Zin Min Htet No relevant relationships by Zinobia Khan No relevant relationships by Shiny Teja Kolli No relevant relationships by Praveen Kumar Komminni No relevant relationships by Zin Thawdar Oo" @default.
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• W4387249548 date "2023-10-01" @default.
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• W4387249548 title "BEVACIZUMAB WITH COCAINE CAUSED MULTIPLE INTRAPARENCHYMAL CEREBRAL HEMORRHAGE" @default.
• W4387249548 doi "https://doi.org/10.1016/j.chest.2023.07.1810" @default.
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