eComment. Anticoagulation after intracranial haemorrhage in patients with a high risk of thrombosis

We have read with great interest the article by Chandra and colleagues [1]. Anticoagulation in patients with warfarin-associated intracranial haemorrhage and a high risk of thrombosis and embolism are difficult questions in modern practice. It applies not only to patients with prosthetic heart valves, but also with venous thrombosis, atrial fibrillation, etc. The frequency of this complication is about 0.25-1.1% per year [2]. According to the study by Yung et al., the predictors of mortality in patients with warfarin-associated intracranial haemorrhage are the degree of initial anticoagulation (INR >3), greater stroke severity and intraventricular haemorrhage [2]. In other words, the amount and duration of bleeding depending on the capacity of the coagulation of blood determines the degree of the brain damage. So we need a rapid and careful recruitment of coagulation, which can be achieved by using the prothrombin complex concentrates. Vitamin K and fresh frozen plasma cannot fully satisfy these requirements. To reduce the risk of thrombotic events, prothrombin complex concentrates should be used, which comprise the proteins C and S. The frequency of thrombotic complications in that case does not exceed 1% [3]. Anticoagulant therapy may be resumed after the normalization of the INR, but not before carrying out neurosurgical intervention, if necessary. For its performance, we recommend using anticoagulants with a short half-life, such as unfractionated heparin or bivalirudin. It is advisable to administer these drugs with continuous intravenous infusion and close monitoring of partial thromboplastin time (PTT) (or ecarin clotting time for bivalirudin). The normal range of these coagulation parameters should be above 1.5-2. In case of re-bleeding, the infusion of anticoagulation drugs can be stopped easily. It is noted that Bertram et al. showed no rebleeding after intracerebral haemorrhage in patients with the normal INR and increased PTT values [4]. Subsequently patients should receive the anticoagulants with prolonged action, prescribed in the hospital. A number of studies have shown a lower risk of intracranial haemorrhage in patients who received non-warfarin anticoagulant therapy, for instance antiplatelet drugs, factor Xa inhibitors [5].

Therefore, for the primary prevention of intracranial haemorrhage in high-risk patients (advanced age, hypertension, prior ischaemic stroke, diabetes mellitus, and alcohol abuse) requiring antithrombotic therapy, alternative drugs should be considered.

Conflict of interest: none declared.