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Intracranial Hemorrhage in Anticoagulated Patients

What should a clinician do when an anticoagulated patient with high thromboembolic risk suffers an intracranial hemorrhage? This question was addressed in a retrospective study of 141 patients at Mayo Clinic who suffered intracranial hemorrhages during warfarin anticoagulation. Prior to the hemorrhage, they had received anticoagulants for an average 5 years because of prosthetic heart valves (37 percent), histories of embolic stroke with atrial fibrillation (38 percent), or previous stroke or TIA while receiving antiplatelet therapy (25 percent).

Anticoagulation was reversed in all patients at the time of admission, and warfarin was withheld for a median of 10 days. Three patients had ischemic events while off anticoagulation. Among 35 patients in whom anticoagulation with heparin or warfarin was restarted during hospitalization, none had recurrent intracranial hemorrhages. The in-hospital mortality rate was 43 percent.

Comment: This retrospective study is far from ideal: We don't know exactly how treatment decisions were made, and undetected thromboses or recurrent bleeding might have contributed to some of the deaths. Nevertheless, these data may well be the best we can expect in the foreseeable future: They suggest that a 1- to 2-week period off anticoagulants, followed by resumption of anticoagulation, is reasonably safe in the short term.

— AS Brett

Published in Journal Watch General Medicine January 12, 2001

Citation(s):

Phan TG et al. Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. Arch Neurol 2000 Dec 57 1710-1713.

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