Anticoagulant Related Hemorrhage

Chronic anticoagulation, often for the purpose of preventing ischemic stroke, is a risk factor for ICH. It also appears to be associated with an increased likelihood of a poor outcome in patients who suffer an ICH. Two early reports focused on prognosis in anticoagulant-related hemorrhage. One reported that 20 of 40 patients did not survive, but 18 of 20 survivors recovered completely. Five patients suffered concomitant subdural hematomas, but no patients had multiple ICHs (59). The second report found that 28 of a series of 200 patients with ICH had been taking warfarin at the time of the hemorrhage (57). The mortality of the entire group was 30%, but 57% of those with anticoagulant-related hemorrhages died. The anticoagulant-related hemorrhages were also larger on average (57). A 2004 study attempted to quantify the independent effect, on ICH prognosis, of anticoagulation with warfarin by assessing 435 consecutive ICH patients over age 55, of whom 102 were taking warfarin at the time of hemorrhage (60). The use of warfarin more than doubled the 3-month mortality rate. Higher admission international normalized ratio (INRs) were associated with greater mortality. Hemorrhage size was not measured in this study. Several studies, including the second that is cited above (57) , have suggested that patients with anticoagulant-related hemorrhages have larger hemorrhages; thus, warfarin use might simply be acting as a proxy for hemorrhage size. However, in a Taiwanese study that excluded anticoagulated patients, prothrombin times were significantly higher among nonsurvivors after adjusting for initial hemorrhage size (55), suggesting that noniatrogenic coagulopathies might play a more important role in ICH than is currently appreciated. Anticoagulant-related ICH may also have a greater likelihood of expansion (see below). Regardless of the etiology, anticoagulant-related hemorrhages tend to be larger, with a poorer prognosis. Hemorrhage size, IVH, and level of consciousness or GCS continue to predict outcome accurately in these patients, as they do for most patients with ICH.

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