Abstract
Purpose
A nationwide survey was conducted regarding anticoagulant therapy in patients with
acute intracerebral hemorrhage (ICH) on warfarin with nonvalvular atrial fibrillation
(NVAF).
Methods
A questionnaire on standard therapeutic strategy for warfarin-related ICH in patients
with NVAF was mailed to 416 institutes.
Results
A total of 329 physicians (79%) responded with a completed questionnaire. On admission,
all respondents stopped warfarin medication and 94% normalized the international normalized
ratio (INR) mainly by Vitamin K (63%), followed by fresh frozen plasma (20%), and
prothrombin complex concentrate (10%). Afterwards, 91% of the respondents restarted
anticoagulation and 3% used antiplatelet for prevention of thromboembolism, but the
remaining 6% disagreed with restarting antithrombotic therapy. As contraindications
for resuming anticoagulation, recurrent ICH (59%) and poor functional condition (59%)
were often chosen. Of those who restarted anticoagulation, the timing was within 4 days in 7%, 5 to 7 days in 21%, 8 to 14 days in 25%, 15 to 28 days in 28% and 29 days or later in 18%. The major key finding on follow-up CT to restart anticoagulation
was the absorption tendency of hematomas (47%). When restarting anticoagulation, 76%
of the respondents used warfarin alone and 20% used either unfractionated heparin
plus warfarin or heparin alone.
Conclusion
A large majority of respondents responsible for ICH management stopped oral warfarin
medication and normalized INR on admission, and restarted anticoagulation after acute
ICH in patients with NVAF. However, the strategies to normalize INR and to restart
anticoagulant therapy varied greatly and depended on each individual physician's decision.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the Neurological SciencesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses.Stroke. 1995; 26: 1471-1477
- The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage.Arch Intern Med. 2004; 164: 880-884
- Bleeding with Antithrombotic Therapy (BAT) Study Group. Dual antithrombotic therapy increases severe bleeding events in patients with stroke and cardiovascular disease: a prospective, multicenter, observational study.Stroke. 2008; 39: 1740-1745
- Predisposing factors to enlargement of spontaneous intracerebral hematoma.Stroke. 1997; 28: 2370-2375
- Bleeding with Antithrombotic Therapy Study Group. Antithrombotic therapy influences location, enlargement, and mortality from intracerebral hemorrhage: the Bleeding with Antithrombotic Therapy (BAT) Retrospective Study.Cerebrovasc Dis. 2009; 27: 151-159
- Predisposing factors for enlargement of intracerebral hemorrhage in patients treated with warfarin.Thromb Haemost. 2003; 89: 278-283
- Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage.Neurology. 2004; 63: 1059-1064
- Early hemorrhage growth in patients with intracerebral hemorrhage.Stroke. 1997; 28: 1-5
- Enlargement of spontaneous intracerebral hemorrhage: incidence and time course.Stroke. 1996; 27: 1783-1787
- Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage.Stroke. 1998; 29: 1160-1166
- Prevalence of venous thromboembolism in acute hemorrhagic and thromboembolic stroke.Am J Phys Med Rehabil. 2003; 82: 364-369
- Diagnosis of lower-limb deep vein thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging.Ann Intern Med. 2002; 136: 89-98
- Sex differences in the prevalence of deep-vein thrombosis in Japanese patients with acute intracerebral hemorrhage.Cerebrovasc Dis. 2009; 27: 313-319
- Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) Study Investigators. Nationwide survey of antihypertensive treatment for acute intracerebral hemorrhage in Japan.Hypertens Res. 2009; 32: 759-764
- Recommendations for the management of intracranial haemorrhage part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee.Cerebrovasc Dis. 2006; 22: 294-316
- American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2010; 41: 2108-2129
- The Joint Committee on Guidelines for the Management of Stroke.in: Japanese Guidelines for the Management of Stroke 2009. Kyowa Kikaku, Ltd, Tokyo2009
- Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy.Thromb Haemost. 1997; 77: 477-480
- Emergency reversal of anticoagulation after intracerebral hemorrhage.Stroke. 1992; 23: 972-977
- Correction of INR by prothrombin complex concentrate and vitamin K in patients with warfarin related hemorrhagic complication.Thromb Res. 2002; 108: 25-30
- Cerebral microbleeds are a risk factor for warfarin-related intracerebral hemorrhage.Neurology. 2009; 72: 171-176
- Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators.Am Coll Cardiol. 2000; 35: 183-187
- Management of intracranial hemorrhage associated with anticoagulant therapy.Surg Neurol. 1995; 44: 438-442
- The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves.Neurosurgery. 1998; 42: 769-773
- Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk.Arch Neurol. 2000; 57: 1710-1713
Article info
Publication history
Published online: August 29, 2011
Accepted:
August 8,
2011
Received in revised form:
August 4,
2011
Received:
June 10,
2011
Identification
Copyright
© 2011 Elsevier B.V. Published by Elsevier Inc. All rights reserved.
