Anticoagulation or Inferior Vena Cava Filter Placement for Patients With Primary Intracerebral Hemorrhage Developing Venous Thromboembolism?

Abstract

Background-Most patients with primary intracerebral hemorrhage developing clinically apparent proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) require treatment with either anticoagulants or inferior vena cava filter insertion. Although the latter probably reduces the immediate risk of incident or recurrent PE and surmounts the undefined risk of recurrent intracranial bleeding with anticoagulation, the issue of preventing further thrombus propagation is not addressed, and there are associated short-and long-term risks, including a greater incidence of recurrent DVT. Summary of Review-There are no data from randomized trials to clarify optimum treatment in these patients; indeed, the feasibility of such studies is questionable. Hence, treatment decisions continue to be made on an individualized basis and should include assimilation of information on key factors such as time elapsed post-stroke and lobar versus deep hemispheric location of the index event, natural history studies demonstrating a two-fold risk of recurrent intracerebral hemorrhage in the former subgroup. Conclusions-In patients selected for anticoagulation, data from nonstroke patients suggest that a 5-to 10-day course of full-dose low-molecular-weight heparin followed by 3 months of lower-dose low-molecular-weight heparin is at least as effective as warfarin and may be associated with fewer hemorrhagic complications.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

“…Only very limited information is available to guide decision making on IVC filter placement versus anticoagulation, as well as the optimal anticoagulation regimen. 119 Considerations include the posthemorrhage date on which DVT/PE is diagnosed, documentation of stable hematoma size on neuroimaging, lobar versus deep hematoma location, and the practical ability to remove an IVC filter at a later date. General guidelines for the use of IVC filters in the setting of acute DVT suggest a conventional course of anticoagulant therapy if the risk of bleeding resolves; however, these are not ICH specific.…”

Reprint

“…102 Vena cava filters may reduce the incidence of pulmonary embolism in patients with proximal deep vein thrombosis in the first several weeks but have a longer-term risk of increased venous thromboembolism. 102,103 No randomized clinical trial has compared vena cava filters with anticoagulation in patients with ICH or ischemic stroke.…”

Update on intracerebral haemorrhage

“…ICH patients suffering a deep venous thrombosis or pulmonary embolism require full anticoagulation with IV heparin or LMWH or the insertion of a inferior vena cava filter. A short course (5 to 10 days) of full-dose LMWH followed by lowdose LMWH for 3 -6 months may be associated with less haemorrhagic complications than LMWH followed by warfarin [55]. Antiplatelet agents may be indicated because of other thrombotic complications including acute myocardial infarction and ischaemic stroke.…”