Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk

Abstract

To cite this article: Hawryluk GWJ, Austin JW, Furlan JC, Lee JB, OÕKelly C, Fehlings MG. Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk. J Thromb Haemost 2010; 8: 1500-8. Summary. Background:Patients who present with central nervous system (CNS) hemorrhage while on anticoagulation (AC) for thromboembolic (TE) risk factors are a challenge to manage. Objective: We sought to inform decisions surrounding the timing and intensity of AC resumption by performing a systematic review. Methods: Three reviewers screened publications from Medline and EMBASE and extracted data. Hemorrhagic and TE adverse events that occurred subsequent to the index hemorrhage were recorded, as was their timing relative to presentation and covariates that might influence their occurrence. Results: Data were extracted from 63 publications detailing 492 patients; 7.7% of patients experienced hemorrhagic complications and 6.1% experienced TE complications. Hemorrhagic complications were more common within 72 h of presentation while TE complications were more common thereafter. Patients restarted on AC after 72 h were significantly more likely to have a TE complication (P = 0.006) and those restarted before 72 h were more likely to hemorrhage (P = 0.0727). Factors associated with rehemorrhage included younger age, traumatic cause, subdural hematomas and failure to reverse AC. TE complications were more common in younger patients and those with spinal hemorrhage, multiple hemorrhages, and non-traumatic causes of the index hemorrhage. Re-initiation of AC at a lower intensity also significantly increased the risk of TE complications. Interpretation: Our results suggest that it may be prudent to re-initiate AC earlier than previously thought, with the timing and intensity modified based on predictors of TE and hemorrhagic complications. These findings must be explored in a prospective study because of limitations inherent to the analyzed studies.

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

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Optimal Timing of Resumption of Warfarin After Intracranial Hemorrhage

“…A recently published systematic review with 492 patients concluded that anticoagulation may be resumed after 72 hours. 17 This review included a large number of single-case reports with a high risk for bias toward successful cases, and the authors considered all anticoagulants of any dose together. The hitherto largest cohort included 141 patients, of whom 35 patients resumed warfarin; however, the follow-up was only 30 days, which may explain why no recurrent intracranial hemorrhage was observed.…”

Secondary Intracerebral Hemorrhage Due to Early Initiation of Oral Anticoagulation After Ischemic Stroke

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