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Intracerebral hemorrhage in stroke patients anticoagulated with heparin
V L Babikian1, C S Kase, M S Pessin
1Department of Neurology, Boston University School of Medicine, MA 02130.
Insights
Heparin anticoagulation can cause early intracerebral hemorrhage in acute cerebral infarction patients, often within 24 hours of starting treatment. This complication is frequently linked to moderate to large infarcts and sometimes excessive anticoagulation levels.
Area of Science:
- Neurology
- Hematology
Background:
- Acute cerebral infarction (stroke) is a leading cause of disability.
- Heparin anticoagulation is used to prevent and treat thromboembolic events.
- Intracerebral hemorrhage (ICH) is a serious complication of anticoagulation therapy.
Purpose of the Study:
- To characterize the clinical features of patients experiencing ICH during heparin anticoagulation for acute cerebral infarction.
- To identify risk factors and timing associated with heparin-induced ICH in stroke patients.
Main Methods:
- Retrospective case series of 10 patients with acute cerebral infarction and heparin-related ICH.
- Literature review of 16 previously reported cases.
- Analysis of clinical features, infarct characteristics, and anticoagulation parameters.
Main Results:
- ICH occurred early, typically within 72 hours of stroke onset and often within 24 hours of heparin initiation.
- Moderate-to-large infarcts in the middle cerebral artery territory were common (90%).
- Excessive anticoagulation (aPTT > 2x control) was noted in several patients.
Conclusions:
- Heparin-related ICH in acute cerebral infarction is an early complication.
- It is often associated with significant infarcts and may occur with supratherapeutic anticoagulation.
- Early recognition and management are crucial for patient outcomes.
Abstract:
To characterize the clinical features of patients with acute cerebral infarction who sustained intracerebral hemorrhage related to heparin anticoagulation, we describe 10 patients and review reports of 16 cases. Cardiac-source embolism was identified in seven (70%) of the 10 patients and consisted of atrial fibrillation in six of the seven. The middle cerebral artery territory was affected in nine patients (90%), with moderate-sized or large infarcts by clinical and computed tomographic criteria. The interval between stroke onset and intracerebral hemorrhage was less than 72 hours in 80% of the patients. Intracerebral hemorrhage occurred less than or equal to 24 hours after the time heparin was started in 80% of the patients. The activated partial thromboplastin time closest to the time of intracerebral hemorrhage was greater than 2 x control in seven patients. Our findings in the 10 patients are similar to those of the 16 cases previously reported and suggest that heparin-related intracerebral hemorrhage occurs early after stroke onset, usually with moderate-sized or large infarcts, and with excessive anticoagulation in some patients.