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Need for continued use of anticoagulants after intracerebral hemorrhage

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Opinion statement

One of the unsolved dilemmas in cerebrovascular disease is the ideal timing to restart anticoagulant therapy (ACT) safely in patients who have suffered an intracranial hemorrhage and have an indication to continue ACT. No randomized studies with evidence-based data are available to settle this issue. Only a few reports have been published; their shortcomings include small numbers of patients evaluated retrospectively, a broad spectrum of indications for ACT, different types of hemorrhage, and variable methods of reversing and restarting ACT. Despite this variability, most reports agree that 1) ACT has to be immediately reversed to decrease the risk of hemorrhage progression; 2) a period between 1 and 2 weeks appears sufficient to allow for management and monitoring of the hemorrhage off ACT; and 3) ACT can be safely restarted after the period off of treatment. A physician confronting a patient with intracranial hemorrhage and the need for ACT faces a situation of individually focused clinical decision making. The problem rests in balancing the risks of a worsening or recurring hemorrhage on one side, and the risk of thromboembolism on the other. From available information and personal experience, an unvalidated risk stratification can be proposed to categorize patients in low- and high-risk groups for hemorrhagic complications and embolic phenomena, assigning them to 5 or 15 days off ACT, respectively. Intermediate-risk patients can have ACT restarted in 5 to 15 days from the onset of the intracranial hemorrhage. Anticoagulation should be immediately reversed. Fresh frozen plasma is the standard treatment in most institutions. Prothrombin complex concentrate is an alternative, but issues of availability make its use impractical. The use of recombinant factor VIIa is an attractive new option.

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References and Recommended Reading

  1. Hart RG, Boop BS, Anderson DC: Oral anticoagulants and intracerebral hemorrhage: facts and hypotheses. Stroke 1995, 26:1471–1477.

    PubMed  CAS  Google Scholar 

  2. Smith EE, Rosand J, Knudsen KA, et al.: Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke. Neurology 2002, 59:193–197.

    PubMed  CAS  Google Scholar 

  3. Cannegieter SC, Rosendaal FR, Briet E: Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994, 89:635–641.

    PubMed  CAS  Google Scholar 

  4. Cannegieter SC, Rosendaal FR, Wintzen AR, et al.: Optimal oral anticoagulation therapy in patients with mechanical heart valves. N Engl J Med 1995, 333:11–17.

    Article  PubMed  CAS  Google Scholar 

  5. van Walraven C, Hart RG, Singer DE, et al.: Oral antico-agulation vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 2002, 288:2441–2448.

    Article  PubMed  Google Scholar 

  6. Stewart S, Hart CL, Hole DJ, McMurray JJ: A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew-Paisley Study. Am J Med 2002, 113:359–364.

    Article  PubMed  Google Scholar 

  7. Design, progress and challenges of a double-blind trial of warfarin versus aspirin for symptomatic intracranial arterial stenosis. Warfarin Aspirin Symptomatic Intracranial Disease (WASID) Trial Investigators [no authors listed]. Neuroepidemiology 2003, 22:106–117.

  8. Rinkel GJ, Prins NE, Algra A: Outcome of aneurysmal subarachnoid hemorrhage in patients on anticoagulant treatment. Stroke 1997, 28:6–9.

    PubMed  CAS  Google Scholar 

  9. Phan TG, Koh M, Wijdicks EFM: Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. Arch Neurol 2000, 57:1710–1713. Albeit retrospective, this is the largest series of patients combining a broad spectrum of hemorrhage etiologies, locations, and indications for anticoagulation.

    Article  PubMed  CAS  Google Scholar 

  10. Bertram M, Bonsanto M, Hacke W, Schwab S: Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for antico-agulation. J Neurol 2000, 247:209–214. A small series, although valuable because patients were recently managed with state-of-the-art treatment at a sophisti-cated neurointensive care unit.

    Article  PubMed  CAS  Google Scholar 

  11. Wijdicks EFM, Schievink WI, Brown RD, Mullany CHJ: The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves. Neurosurgery 1998, 42:769–773.

    Article  PubMed  CAS  Google Scholar 

  12. Butler AC, Tait RC: Restarting anticoagulation in prosthetic heart valve patients after intracranial hemor-rhage: a 2-year follow-up. Brit J Haematol 1998, 103:1064–1066.

    Article  CAS  Google Scholar 

  13. Fredriksson K, Norrving B, Stromblad LG: Emergency reversal of anticoagulation after intracerebral hemor-rhage. Stroke 1992, 23:972–977.

    PubMed  CAS  Google Scholar 

  14. Deveras RA, Kessler CM: Reversal of warfarin induced excessive anticoagulation with recombinant human factor VIIa concentrate. Ann Intern Med 2002, 137:884–888. A most important report on the use of recombinant factor VIIa, which will probably become a "breakthrough" novel treatment of hemorrhagic complications with or without associated abnormalities of coagulation factors.

    PubMed  CAS  Google Scholar 

  15. Mayer SA: Ultra-early hemostatic therapy for intracere-bral hemorrhage. Stroke 2003, 34:224–229.

    Article  PubMed  Google Scholar 

  16. Leker RR, Abramsky O: Early anticoagulation in patients with prosthetic heart valves and intracerebral hematoma. Neurology 1998, 50:1489–1491.

    PubMed  CAS  Google Scholar 

  17. Hacke W: The dilemma of reinstituting anticoagulation for patients with cardioembolic sources and intracranial hemorrhage. Arch Neurol 2000, 57:1682–1684. The expert’s view: well written, critical, updated, and comprehensive.

    Article  PubMed  CAS  Google Scholar 

  18. Babikian VL, Kase CS, Pessin MS, et al.: Resumption of anticoagulation after intracranial bleeding in patients with prosthetic heart valves. Stroke 1988, 19:407–408.

    PubMed  CAS  Google Scholar 

  19. Toth C, Voll C: Validation of a weight-based nomo-gram for the use of intravenous heparin in transient ischemic attack or stroke. Stroke 2002, 33:670–674. A very practical tool for a more reliable, yet easy to use, control of IV heparin dosage.

    Article  PubMed  Google Scholar 

  20. Albers GW, Easton JD, Sacco RL, Teal P: Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 1998, 114:683S-698S.

    PubMed  CAS  Google Scholar 

  21. Kay R, Wong KS, Lu YL: Low molecular weight heparin for the treatment of acute ischemic stroke. N Engl J Med 1995, 333:1588–1593.

    Article  PubMed  CAS  Google Scholar 

  22. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. The French Study of Aortic Plaques in Stroke Group [no authors listed]. N Engl J Med 1996, 334:1216–1221.

  23. Miller LG: Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998, 158:2200–2211.

    Article  PubMed  CAS  Google Scholar 

  24. Wahl MJ: Dental surgery in anticoagulated patients. Arch Intern Med 1998, 158:1610–1616.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Boston University School of Medicine, 715 Albany Street, Neurology B-605, 02118-2526, Boston, MA, USA

    Carlos S. Kase MD

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  1. Conrado J. Estol MD
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  2. Carlos S. Kase MD
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Estol, C.J., Kase, C.S. Need for continued use of anticoagulants after intracerebral hemorrhage. Curr Treat Options Cardio Med 5, 201–209 (2003). https://doi.org/10.1007/s11936-003-0004-1

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  • DOI: https://doi.org/10.1007/s11936-003-0004-1

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