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).
Epidemiology
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.
Diagnosis
Management
Outcome
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).