Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation

Physicians face a therapeutic dilemma in patients with acute hemorrhagic st roke requiring long-term, high-intensity anticoagulants because this treatm ent increases the risk of intracranial hemorrhage (ICH) 8- to 11-fold. We r etrospectively studied 15 patients with ICH which occurred under anticoagul ation with phenprocoumon, with an international normalized ratio (INR) of 2 .5-6.5 on admission. Hemispheric, thalamic, cerebellar, intraventricular, o r subarachnoid hemorrhage without aneurysm occurred. Absolute indications f br anticoagulation were double, mitral, or aortic valve replacement, combin ed mitral valve failure with atrial fibrillation and atrial enlargement, in ternal carotid artery-jugular vein graft, frequently recurring deep vein th rombosis with risk of pulmonary embolism, and severe nontreatable ischemic heart disease. As soon as the diagnosis of ICH was established, INR normali zation was attempted in all patients by administration of prothrombin compl ex, fresh frozen plasma, or vitamin K. After giving phenprocoumon antagonis ts (and neurosurgical therapy in four patients) heparin administration was started. Nine patients received full-dose intravenous and six low-dose subc utaneous heparin. The following observations were made: (a) All patients wi th effective, full-dose heparin treatment with a 1.5- to 2-fold elevation i n partial thromboplastin time after normalization of the INR were discharge d without complication. (b) Three of four of the patients with only incompl ete correction of the INR (> 1.35) experienced relevant rebleeding within 3 days (all patients with an INR higher than 1.5), two of whom were on full- dose heparin. (c) Three of seven of the patients with normalized INR and wi thout significant PTT elevation developed severe cerebral embolism. Althoug h our data are based on a retrospective analysis, they support treatment wi th intravenous heparin (partial thromboplastin time 1.5-2 times baseline va lue) after normalization of the INR in patients with an ICH and an urgent n eed for anticoagulation.