THE DILEMMA OF DISCONTINUATION OF ANTICOAGULATION THERAPY FOR PATIENTS WITH INTRACRANIAL HEMORRHAGE AND MECHANICAL HEART-VALVES

BACKGROUND: Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, ear ly reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patient s at risk for systemic embolization involving the brain. The risk of e mbolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular func tion. This dilemma exists because of a lack of data for a large series of patients. METHODS: We reviewed the medical records and neuroimagin g studies for a consecutive group of patients admitted with intracrani al hemorrhage and mechanical heart valves. We reviewed neurological pr esenting data, cardiac risk factors for systemic embolization (atrial fibrillation, enlarged atrial chambers, reduced ventricular function, and the type and location of the metallic valve), and hospital managem ent. RESULTS: We studied 39 patients with intracranial hemorrhage and mechanical heart valves (median age, 69 yr). Four patients had experie nced previous transient ischemic attacks or minor strokes. The time fr om valve replacement to intracranial hemorrhage ranged from 2 months t o 19 years (median, 6 yr). The type of intracranial hemorrhage was acu te subdural hematoma (n = 20), lobar hematoma (n = 10), subarachnoid h emorrhage (n = 4), cerebellar hematoma (n = 3), or basal ganglionic he matoma (n = 2). Thirteen patients died within 2 days of admission. All 26 surviving patients received fresh frozen plasma and vitamin K. Fif teen patients underwent evacuation of acute subdural hematoma, and in one patient an anterior communicating aneurysm was clipped. The durati on of discontinuation of anticoagulation therapy varied from 2 days to 3 months (median, 8 d). None of the patients developed transient isch emic attacks, ischemic strokes, valve thrombosis, or systemic emboliza tion. No recurrence of intracranial hemorrhaging was observed during h ospitalization and reinstitution of anticoagulation or antiplatelet ag ent administration. CONCLUSION: Temporary interruption of anticoagulat ion therapy seems safe for patients with intracranial hemorrhage and m echanical heart valves but without previous evidence of systemic embol ization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to dip or coil a ruptured aneurysm, or to evacuate an acute subdural hematom a.