INTRACEREBRAL HEMORRHAGE
Risk and prevention of bleeding in anticoagulant therapy
Created 15/04/2021, last revision 29/04/2023
- anticoagulant therapy is associated with an increased risk of clinically significant bleeding
- antiplatelet therapy, however, is not a safe and effective substitute
- specific scales can assess the risk of bleeding individually (see below)
- always weigh the benefit of therapy against its risk
- risk of bleeding (mainly intracranial): DOAC < warfarin
Etiopathogenesis of anticoagulation-related bleeding
- the anticoagulants are associated with an increased risk of bleeding, and this bleeding is more likely clinically significant
- several factors can trigger intracerebral bleeding → see here
- artery rupture in a hypertensive patient (hypertensive arteriolopathy)
- according to the CROMIS-2 trial, cerebral microbleeds (CMBs) on GRE doubles the risk of bleeding
- according to the CROMIS-2 trial, cerebral microbleeds (CMBs) on GRE doubles the risk of bleeding
- rupture of vascular malformation
- cerebral amyloid angiopathy (CAA)
- trauma
- tumor invasion
- sepsis
- hemorrhagic stroke
- artery rupture in a hypertensive patient (hypertensive arteriolopathy)
- screening for occult bleeding, malformation, or CMBs is not part of routine procedures before starting anticoagulant therapy
- systemic bleeding most usually occurs in GI or urogenital tract
Risk factors
- modifiable risk factors
- blood pressure
- drug interactions
- the correct dose of the anticoagulant drug (e.g., regarding weight and/or renal function)
- mon-modifiable risk factors (cannot be changed)
- age
- race
- comorbidities (renal insufficiency, hepatopathy, etc.)
- previous ICH (Schreuder, 2021)
Anticoagulant drug and dose
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Age, race
- older age is associated with a higher risk of bleeding, but it is not a reason to withhold the therapy
- dabigatran dose should be reduced at ages ≥ 75-80 (see specifics of each drug)
- race – higher risk in Asians, Hispanics, and blacks
Recent ischemic stroke
- in the first days-weeks after a stroke, there is an increased risk of bleeding within the ischemic area (hemorrhagic transformation of ischemia)
- timing of anticoagulation is guided by the patient’s clinical status (NIHSS), compensation of risk factors (BP, platelets count, coagulation), and CT scan findings (localization and extent of ischemia)
History of bleeding
- previous bleeding increases the risk of recurrence
- individual assessment is necessary, but reinstitution of anticoagulant therapy is usually possible and associated with reduced overall mortality [Witt, 2018]
- risk of GI bleeding can be assessed by endoscopic findings
- risk of IC bleeding depends on the etiology and compensation of modifiable risk factors
- postoperative bleeding is a transient risk factor
Other comorbidities
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Thrombocytopenia and thrombocytopathy
Other specific risk factors
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Bleeding risk scales
Reduction of bleeding risks
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