Risk of intracerebral bleeding in patients treated with anticoagulants
- W David Freeman, MD
W David Freeman, MD
- Professor of Neurology
- Mayo Clinic
- Maria I Aguilar, MD
Maria I Aguilar, MD
- Associate Professor of Neurology
- Mayo Clinic Arizona
- Jeffrey Weitz, MD
Jeffrey Weitz, MD
- Professor of Medicine and Biochemistry
- McMaster University
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Jose Biller, MD, FACP, FAAN, FAHA
Jose Biller, MD, FACP, FAAN, FAHA
- Section Editor — Stroke
- Professor of Neurology and Neurological Surgery
- Chairman Department of Neurology
- Loyola University Chicago
- Stritch School of Medicine
Antithrombotic therapies (eg, antiplatelet agents, heparins, vitamin K antagonists, direct thrombin inhibitors, direct factor Xa inhibitors) are widely used in clinical medicine based upon well-designed randomized clinical trials that have rigorously defined their benefits relative to associated bleeding risks. In most of these trials, patients presumed to be at especially high risk for intracerebral hemorrhage (ICH) were excluded from participation, in large part because the antithrombotic benefits were yet to be fully defined while the bleeding risks appeared unduly high.
Because of under-representation in clinical trials, determining the relative efficacy and safety of antithrombotic agents in patients at varying increased risks for ICH is problematic. Nevertheless, clinicians are regularly faced with risk/benefit decisions regarding antithrombotic therapy for such patients. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization" and "Anticoagulation in older adults", section on 'Considerations about treatment choices'.)
The risk of intracerebral hemorrhage in patients treated with warfarin and other vitamin K antagonists will be reviewed here. Other related topic reviews include the following:
●Risk of intracerebral bleeding associated with antiplatelet therapy (see "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Antithrombotic therapy')
●Risk of subdural hematoma in patients on anticoagulants are presented separately (see "Subdural hematoma in adults: Etiology, clinical features, and diagnosis")
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- ICH RISK WITH ANTITHROMBOTIC THERAPY
- Effect of ethnicity
- Dabigatran, rivaroxaban, apixaban
- Cerebral microbleeds
- PREDICTORS OF RISK
- Intensity of anticoagulation
- Blood pressure control
- Advanced age
- - Evaluating head trauma
- Concomitant aspirin use
- Imaging and genetic markers
- - Imaging cerebral microbleeds
- REDUCING THE RISK OF ICH DURING ANTICOAGULANT THERAPY
- SUMMARY AND RECOMMENDATIONS