Skip to main content

Symptomatic intracerebral hematomas in posterior circulation stroke patients anticoagulated with heparin

Journal of Thrombosis and Thrombolysis volume 21, pages 249–255 (2006)Cite this article

Abstract

Background: A lot of clinicians use heparin in patients with posterior circulation stroke. Frequency and risk factors of symptomatic intracerebral hematoma (ICH) in posterior circulation infarct patients anticoagulated with unfractionated heparin are not known.

Methods: To determine the incidence and the risk factors of the heparin-related ICH in posterior circulation infarct patients, we retrospectively reviewed the clinical features of 37 patients who had acute posterior circulation infarct and received intravenous heparin after they underwent brain computed tomographic scans and diffusion-weighted imaging (DWI). Follow-up brain scans were obtained at any time if clinical symptoms worsened. Volumes of acute posterior circulation infarction were calculated on DWI.

Results: Of 37 patients, four (10.8%) developed symptomatic ICH during heparin infusion. The location of ICH was cerebellum in all the hemorrhagic worsening patients. We found that the size of an acute infarction calculated on DWI is the risk factor of symptomatic ICH during intravenous heparin therapy in patients with posterior circulation infarct.

Conclusions: Until a large prospective study is performed, it may be prudent to avoid heparin infusion in patients with large posterior circulation infarct documented on DWI.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

References

  1. Millikan CH (1971) Reassessment of anticoagulation therapy in various type of occlusive cerebrovascular disease. Stroke 2:201–208

    CAS  PubMed  Google Scholar 

  2. Millikan CH, Siekert RG, Shick RM (1955) Studies in cerebrovascular disease. III. The use of anticoagulant drugs in the treatment of insufficiency or thrombosis within the basilar arterial system. Mayo Clin Proc 30:116–126

    CAS  PubMed  Google Scholar 

  3. Millikan CG, Siekert RG, Whisnant JP (1958) Anticoagulant therapy in cerebrovascular disease: Current status. JAMA 166:587–592

    CAS  Google Scholar 

  4. Siekert RG, Whisnant JP, Millikan CH (1963) Surgical and anticoagulant therapy of occlusive cerebrovascular disease. Ann Intern Med 58:637–641

    CAS  PubMed  Google Scholar 

  5. Whisnant JP (1961) Discussion. In: Millikan C, Siekert R, Whisnant JP (eds.) Cerebral vascular diseases: Third princeton conference on cerebrovascular diseases. Orlando, Fla, Grune & Stratton, pp. 156–157

    Google Scholar 

  6. Al-Sadat A, Sunbulli M, Chaturvedi S (2002) Use of intravenous heparin by North American neurologists: do the data matter? Stroke 33:1574–1577

    Article  PubMed  Google Scholar 

  7. Tettenborn B (2001) Extended infarcts in the posterior circulation (brainstem/cerebellum). In: Bogousslavsky J, Caplan LR (eds.) Stroke Syndromes, 2nd edition Cambridge, Cambridge University Press, pp. 557–563

    Google Scholar 

  8. Caplan L (2000) Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture-2000. Stroke 31:2011–2023

    CAS  PubMed  Google Scholar 

  9. Victor M, Ropper AH (2001) Cerebrovascular diseases. In: Adams and Victor’s principles of neurology, 7th edn. McGraw-Hill, New York, 821–924

    Google Scholar 

  10. Misra M, Alp MS, Hier D, Ausman JI (2004) Multidisciplinary treatment of posterior circulation ischemia. Neurol Res 26:67–73

    Article  CAS  PubMed  Google Scholar 

  11. Al-Sadat A, Sunbulli M, Chaturvedi S (2002) Use of intravenous heparin by North American neurologists: do the data matter? Stroke 33:1574–1577

    Article  PubMed  Google Scholar 

  12. Yoon SS, Heo SH, Park KC, et al. (2005) The Usage of Intravenous Heparin in Acute Ischemic Stroke in 10 Teaching Hospitals. Journal of the Korean Neurological Association 23:446–450

    Google Scholar 

  13. Adams H, Adams R, Del Zoppo G, Goldstein LB (2005) Stroke Council of the American Heart Association; American Stroke Association. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke 36:916–923

    Article  PubMed  Google Scholar 

  14. International Stroke Trial Collaboration Group (1997). The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute stroke. Lancet 349:1569–1581

    Article  Google Scholar 

  15. Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ (1988) Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 19:1216–1222

    CAS  PubMed  Google Scholar 

  16. Cerebral embolism study group (1983). Immediate anticoagulation of embolic stroke: a randomized trial. Stroke 14:668–676

    Google Scholar 

  17. Calander L, Ortega JF, Berbejo F, Portera A (1983) Cerebral embolism and anticoagulation. (Letter to the editor) Neurology 33:1103–1106

    Google Scholar 

  18. Chamorro A, Vila N, Saiz A, Alday M, Tolosa E (1995) Early anticoagulation after large cerebral embolic infarction: A safety study. Neurology 45:861–865

    CAS  PubMed  Google Scholar 

  19. Chamorro A, Vila N, Ascaso C, Blanc R (1999) Heparin in acute stroke with atrial fibrillation. Clinical relevance of very early treatment. Arch Neurol 56:1098–1102

    Article  CAS  PubMed  Google Scholar 

  20. Camerlingo M, Casto L, Censori B, et al. (1994) Immediate anticoagulation with heparin for first-ever ischemic stroke in the carotid artery territories observed within 5 hours of onset. Arch Neurol 51:462–467

    CAS  PubMed  Google Scholar 

  21. Cerebral embolism study group (1987). Cardioembolic stroke, early anticoagulation, and brain hemorrhage. Arch Intern Med 147:636–640

    Article  Google Scholar 

  22. Cerebral embolism study group (1984). Immediate anticoagulation of embolic stroke: brain hemorrhage and management options. Stroke 15:779–789

    Google Scholar 

  23. Glass TA, Hennessey PM, Pazdera L, et al. (2002) Outcome at 30 days in the New England Medical Center Posterior Circulation Registry. Arch Neurol 59:369–376

    Article  PubMed  Google Scholar 

  24. Kim HJ, Cho HI, Lee DS (2000) Should therapeutic range in heparin therapy be changed with new reagent for activated partial thromboplastin time? Korean J. Med. 59:505–510

    Google Scholar 

  25. Hornig CR, Bauer T, Simon C, Trittmacher S, Dorndorf W (1993) Hemorrhagic transformation in cardioembolic cerebral infarction. Stroke 24:465–468

    CAS  PubMed  Google Scholar 

  26. Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA (1987) MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. AJR 149:351–356

    CAS  PubMed  Google Scholar 

  27. Kase CS, Robinson RK, Stein RW, et al. (1985) Anticoagulant-related intracerebral hemorrhage. Neurology 35:943–948

    CAS  PubMed  Google Scholar 

  28. Radberg JA, Olsson JE, Radberg CT (1991) Prognostic parameters in spontaneous intracerebral hematomas with special reference to anticoagulant treatment. Stroke 22:571–576

    CAS  PubMed  Google Scholar 

  29. Brandt T, von Kummer R, Muller-Kuppers M, Hacke W (1996) Thrombolytic therapy of acute basilar artery occlusion variables affecting recanalization and outcome. Stroke 27:875–881

    CAS  PubMed  Google Scholar 

  30. Hornig CR, Buttner T, Hoffmann O, Dorndorf W (1992) Short-term prognosis of vertebrobasilar ischemic stroke. Cerebrovasc Dis 2:273–281

    Google Scholar 

  31. Lutsep HL, Albers GW, DeCrespigny A, Kamat GN, Marks MP, Moseley ME (1997) Clinical utility of diffusion-weighted magnetic resonance imaging in the assessment of ischemic stroke. Ann Neurol 41:574–580

    Article  CAS  PubMed  Google Scholar 

  32. Fennerty AG, Renowden S, Scolding N, Bentley DP, Campbell IA, Routledge PA (1986) Guidelines to control heparin treatment. Brit Med J 292:579–580

    CAS  Article  Google Scholar 

  33. Elliott GC, Hiltunen SJ, Suchyta M, et al. (1994) Physician-guided treatment compared with a heparin protocol for deep vein thrombosis. Arch Intern Med 154:999–1004

    Article  CAS  PubMed  Google Scholar 

  34. Cory Toth, Chris Voll (2002) Validation of a weight-based nomogram for the use of intravenous heparin in transient ischemic attack or stroke. Stroke 33:670–674

    Article  Google Scholar 

  35. Barnes C, Blanchette V, Canning P, Carcao M (2005) Recombinant FVIIa in the management of intracerebral haemorrhage in severe thrombocytopenia unresponsive to platelet-enhancing treatment. Transfus Med 15:145–150

    Article  CAS  PubMed  Google Scholar 

  36. Nilsson OG, Lindgren A, Stahl N, Brandt L, Saveland H (2000) Incidence of intracerebral and subarachoid hemorrhage in southern Sweden. J Neurol Neurosurg Psych 69:601–607

    Article  CAS  Google Scholar 

  37. Tanaka H, Ueda Y, Date C, et al. (1981) Incidence of stroke in Shibata, Japan, 1976–1978, Stroke 12:460–466

    CAS  PubMed  Google Scholar 

  38. Tanaka A, Ueno Y, Nakayama Y, Takano K, Takebayashi S. (1999) Small chronic hemorrhages and ischemic lesions in association with spontaneous intracerebral hematomas. Stroke 30:1637–1642

    CAS  PubMed  Google Scholar 

  39. Kang K, Lee YS, Kim NH, Kim DE, Park SH (2003) Associated ischemic lesions in intracranial hemorrhage: MRI study. Eur Neurol 49:94–97

    Article  PubMed  Google Scholar 

  40. Smith EE, Rosand J, Knudsen KA, Hylek EM, Greenberg SM (2002) Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke. Neurology 59:193–197

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea

    Kyusik Kang & Byung-Woo Yoon

  2. Department of Neurology, Asan Mental Hospital, Asan-si, Republic of Korea

    K. Kang

Authors
  1. Kyusik Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Byung-Woo Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. K. Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Byung-Woo Yoon.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Kang, K., Yoon, BW. & Kang, K. Symptomatic intracerebral hematomas in posterior circulation stroke patients anticoagulated with heparin. J Thromb Thrombolysis 21, 249–255 (2006). https://doi.org/10.1007/s11239-006-6967-5

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-006-6967-5

Key Words

  • Anticoagulation
  • Diffusion-weighted imaging
  • Heparin
  • Posterior circulation stroke