Anticoagulant Related Intracerebral Hemorrhage

see also Intracranial hemorrhage and anticoagulation.

Intracerebral hemorrhage risk is increased with higher doses than the recommended 100 mg of alteplase (Activase®, recombinant tissue plasminogen activator (rt-PA)) 1) in older patients, in those with anterior MI or higher Killip class, and with bolus administration (vs. infusion) 2).

When heparin was used adjunctively, higher doses were associated with a higher risk of ICH 3) ICH is thought to occur in those patients with some preexisting underlying vascular abnormality 4). Immediate coronary angioplasty is safer than rt-PA when available 5).

Affects up to 1% of patients on oral anticoagulation per year, and is the most feared and devastating complication of this treatment.

Patients with hemorrhage in a lobe or cerebral amyloid angiopathy remain at higher risk for anticoagulant-related intracerebral hemorrhage (ICH) recurrence than thromboembolic events and, therefore would be best managed without anticoagulants.

Anticoagulant Related Intracerebral Hemorrhage Outcome

Intracerebral hemorrhage (ICH) is a life-threatening emergency, the incidence of which has increased in part due to an increase in the use of oral anticoagulants. A blood-fluid level within the hematoma, as revealed by computed tomography (CT), has been suggested as a marker for oral anticoagulant-associated ICH (OAC-ICH), but the diagnostic specificity and prognostic value of this finding remain unclear. In 855 patients with CT-confirmed acute ICH scanned within 48 h of symptom onset, Almarzouki et al. investigated the sensitivity and specificity of the presence of a CT-defined blood-fluid level (rated blinded to anticoagulant status) for identifying concomitant anticoagulant use. They also investigated the association of the presence of a blood-fluid level with six-month case fatality. Eighteen patients (2.1%) had a blood-fluid level identified on CT; of those with a blood-fluid level, 15 (83.3%) were taking anticoagulants. The specificity of the blood-fluid level for OAC-ICH was 99.4%; the sensitivity was 4.2%. We could not detect an association between the presence of a blood-fluid level and an increased risk of death at six months (OR = 1.21, 95% CI 0.28-3.88, p = 0.769). The presence of a blood-fluid level should alert clinicians to the possibility of OAC-ICH, but the absence of a blood-fluid level is not useful in excluding OAC-ICH 6).

Public Health Service. Approval of Thrombolytic Agents. FDA Drug Bull. 1988; 18:6–7
Mehta SR, Eikelboom JW, Yusuf S. Risk of intracranial hemorrhage with bolus versus infusion thrombolytic therapy: a meta-analysis. Lancet. 2000; 356:449–454
Tenecteplase (TNKase) for thrombolysis. Med Letter. 2000; 42:106–108
DaSilva VF, Bormanis J. Intracerebral Hemorrhage After Combined Anticoagulant-Thrombolytic Therapy for Myocardial Infarction: Two Case Reports and a Short Review. Neurosurgery. 1992; 30:943–945
Grines CL, Browne KF, Marco J, et al. A Comparison of Immediate Angioplasty with Thrombolytic Therapy for Acute Myocardial Infarction. N Engl J Med. 1993; 328:673–679
Almarzouki A, Wilson D, Ambler G, Shakeshaft C, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Brown MM, Muir KW, Jäger HR, Werring DJ. Sensitivity and specificity of blood-fluid levels for oral anticoagulant-associated intracerebral hemorrhage. Sci Rep. 2020 Sep 23;10(1):15529. doi: 10.1038/s41598-020-72504-7. Erratum in: Sci Rep. 2021 Apr 28;11(1):9485. PMID: 32968133; PMCID: PMC7511300.
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