Should anticoagulation be resumed after intracerebral hemorrhage?
ABSTRACTIntracerebral hemorrhage (ICH) is the most feared and the most deadly complication of oral anticoagulant therapy, eg, with warfarin (Coumadin). After such an event, clinicians wonder whether their patients should resume anticoagulant therapy. The authors review the management of anticoagulation during and after anticoagulation-associated ICH.
KEY POINTS
- Given the high risk of hematoma expansion in the early phase of acute ICH, most experts recommend reversing anticoagulation immediately.
- Many clinicians start subcutaneous heparinoids in low doses 24 to 72 hours after ICH to prevent deep vein thrombosis, and after the first few days or a week, consider either increasing the dose to a full anticoagulation dose or making a transition to oral anticoagulants.
- Many patients with lobar hemorrhage or cerebral amyloid angiopathy may remain at higher risk of anticoagulant-related ICH recurrence than thromboembolic events and would therefore be best managed without anticoagulants.
- Those with deep hemispheric ICH, hypertension that can be well controlled, and a high risk of disabling thromboembolism may receive net benefit from restarting anticoagulation.
ALTERNATIVES TO WARFARIN
Alternatives to warfarin that show promise in reducing bleeding risk include factor Xa and direct thrombin inhibitors, which may reduce the risk of thromboembolism to an extent similar to that of warfarin, but with fewer bleeding complications.82
In patients with atrial fibrillation, the direct thrombin inhibitor dabigatran (Pradaxa) was shown to prevent ischemic stroke to a similar or greater degree than warfarin, with fewer bleeding complications.83 Further patient follow-up is under way to ensure that this drug does not cause liver problems, as did a similarly designed predecessor.84
The availability of this and other agents in various stages of development82 will probably not make warfarin extinct. Rather, they may change the “tipping point,” the threshold at which the risk of thromboembolism is high enough to justify the risks associated with restarting warfarin therapy. In addition, clinical decision tools clarifying the individual patient’s risk of thromboembolism vs the risk of ICH recurrence will help physicians tailor the therapy to the patient.
For the moment, in situations in which the decision is difficult, maximizing the use of antiplatelet agents offers the best hope.85
RECOMMENDATIONS IN LIEU OF GUIDELINES
In the short term, most patients with ICH will likely benefit from acute reversal of anticoagulation, followed by gradual reinstitution of prophylactic-dose anticoagulation after the first 24 to 72 hours.
In the long term, many patients with lobar hemorrhage, cerebral amyloid angiopathy, or other risk factors may remain at higher risk of anticoagulant-related ICH recurrence than of fatal or disabling thromboembolic events and would therefore be best managed without anticoagulants. Conversely, those with deep hemispheric ICH, hypertension that can be well controlled, and a high risk of disabling thromboembolism may receive a net benefit from restarting anticoagulation.
