Anticoagulation after Intracranial Hemorrhage in Atrial Fibrillation

Do you continue  anticoagulation in a patient who comes in with Intracranial Hemorrhage secondary to anti-coagulation for atrial fibrillation?

  1. In the initial phase, the answer is easy. NO, you immediately discontinue anticoagulation and reverse the Anti-coagulant.
  • For Warfarin, use FFP, Prothrombin Complex Concentrate or Factor VII. If the bleed is critical and the patient needs immediate reversal, go with Factor VII or PCC. Check INR Q4 hrly. Aim for an INR <= 1.3.

Administer first dose of Vitamin K 10 mg IV as soon as possible.

Care should be taken to not be overly aggressive in correcting anticoagulation in patients with small bleeds and metallic valves. I have witnessed more than one patient come in with a small intracranial hemorrhage and suffer an ischemic embolic stroke as a result of over enthusiastic management. To avoid this iatrogenic stroke one should consult with a more experienced intensivist or a neuro-intensivist if possible.

  • For Dabigatran, since we hitherto don’t have an antidote, hemo-dialysis is recommended.
  1. In the later phase, the answer is slightly tougher. YES, as a general rule, we almost always restart anti-coagulation.One strategy to aid in arrival of a decision to continue or discontinue anticoagulation can be made by comparing the CHADS2 score to the HAS-BLED score. Both these scores have been validated in prospective studies and a head to head comparison can be made based on events or bleeds per 100 patient years. Other factors that warrant consideration are patients risk of fall, presence of Amyloid angiopathy (absolute contraindication), aneurysms or vascular malformations.

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