Complication Of Oral Anticoagulant Therapy Research Articles

Cerebral haemorrhage in the patient with atrial fibrillation: do we employ the direct oral anticoagulants without waiting too long?

Intracranial haemorrhage (ICH) is the most feared haemorrhagic complication of oral anticoagulant therapy (OAT), although the risk is significantly lower with direct oral anticoagulants (DOACs) compared with warfarin. Intracranial haemorrhage is generally considered, by clinicians, to be an absolute contraindication to starting or resuming OAT in patients with atrial fibrillation (AF). On the other hand, the pivotal trials with DOACs excluded patients with previous ICH. Observational studies actually indicate a net clinical benefit in favour of DOAC in patients with AF and previous ICH. This benefit is confirmed by randomized clinical trials which, however, have the limitation of the small number of cases, but larger clinical trials comparing DOACs vs. aspirin or no therapy are underway. While OAT is certainly contraindicated in patients with lobar ICH and cerebral amyloid angiopathy, in other cases, the decision must be made in the individual patient through an accurate balance between thromboembolic risk and haemorrhagic risk and a multidisciplinary cardio-neurological evaluation.

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

BackgroundIntracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH. MethodsThis is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed. ResultsThe device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy.The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%. ConclusionsPercutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Acenocoumarol induced intra cerebral haemorrhage

Life threatening intra cerebral haemorrhage (ICH) is the most serious complication of oral anti-coagulation therapy (OAT) with mortality in excess of 50%.early intervention focuses on rapid correction of coagulopathy in order to prevent continued bleeding. Although management guidelines for such haemorrhages are available for the older generation anticoagulants, they are still lacking for newer agents, which are becoming popular among physicians. Supportive care, including blood pressure control, and reversal of anticoagulation remain the cornerstone of acute management of AICH. A case report of young lady of age 29yrs old came with chief compliant of headache, vomiting and involuntary maturation, sudden loss of vision both eyes .she had history of CRHD(chronic rheumatic heart disease) with severe mitral valve stenosis and of post Operative MVR(mitral valve replacement). Altered sensorium after surgery .past medication history was using Acenocoumarol (acenocoumaral) 3mg for 15 days .while observing the patient. Patient was irritable nd abdomen was soft, neck was stiff. Acenocoumarol has been induced intra cerebral haemorrhage in patient and also lead to sub dural haemorrhage infract temporal parietal region

Management of Severe Bleeding in Patients Treated With Oral Anticoagulants: Proceedings Monograph From the Emergency Medicine Cardiac Research and Education Group-International Multidisciplinary Severe Bleeding Consensus Panel October 20, 2018.

In this Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Proceedings Monograph from the October 20, 2018, EMCREG-International Multidisciplinary Consensus Panel on Management of Severe Bleeding in Patients Treated With Oral Anticoagulants held in Orlando, FL, you will find a detailed discussion regarding the treatment of patients requiring anticoagulation and the reversal of anticoagulation for patients with severe bleeding. For emergency physicians, critical care physicians, hospitalists, cardiologists, internists, surgeons, and family physicians, the current approach and disease indications for treatment with anticoagulants such as coumadin, factor IIa, and factor Xa inhibitors are particularly relevant. When a patient treated with anticoagulants presents to the emergency department, intensive care unit, or operating room with severe, uncontrollable bleeding, achieving rapid, controlled hemostasis is critically important to save the patient's life. This EMCREG-International Proceedings Monograph contains multiple sections reflecting critical input from experts in Emergency Cardiovascular Care, Prehospital Emergency Medical Services, Emergency Medicine Operations, Hematology, Hospital Medicine, Neurocritical Care, Cardiovascular Critical Care, Cardiac Electrophysiology, Cardiology, Trauma and Acute Care Surgery, and Pharmacy. The first section provides a description of the current indications for the treatment of patients using oral anticoagulants including coumadin, the factor IIa (thrombin) inhibitor dabigatran, and factor Xa inhibitors such as apixaban and rivaroxaban. In the remaining sections, the treatment of patients presenting to the hospital with major bleeding becomes the focus. The replacement of blood components including red blood cells, platelets, and clotting factors is the critically important initial treatment for these individuals. Reversing the anticoagulated state is also necessary. For patients treated with coumadin, infusion of vitamin K helps to initiate the process of protein synthesis for the vitamin K-dependent coagulation proteins II, VII, IX, and X and the antithrombotic protein C and protein S. Repletion of clotting factors for the patient with 4-factor prothrombin complex concentrate, which includes factors II (prothrombin), VII, IX, and X and therapeutically effective concentrations of the regulatory proteins (protein C and S), provides real-time ability to slow bleeding. For patients treated with the thrombin inhibitor dabigatran, treatment using the highly specific, antibody-derived idarucizumab has been demonstrated to reverse the hypocoagulable state of the patient to allow blood clotting. In May 2018, andexanet alfa was approved by the US Food and Drug Administration to reverse the factor Xa anticoagulants apixaban and rivaroxaban in patients with major bleeding. Before the availability of this highly specific agent, therapy for patients treated with factor Xa inhibitors presenting with severe bleeding usually included replacement of lost blood components including red blood cells, platelets, and clotting factors and 4-factor prothrombin complex concentrate, or if not available, fresh frozen plasma. The evaluation and treatment of the patient with severe bleeding as a complication of oral anticoagulant therapy are discussed from the viewpoint of the emergency physician, neurocritical and cardiovascular critical care intensivist, hematologist, trauma and acute care surgeon, hospitalist, cardiologist, electrophysiologist, and pharmacist in an approach we hope that the reader will find extremely practical and clinically useful. The clinician learner will also find the discussion of the resumption of oral anticoagulation for the patient with severe bleeding after effective treatment important because returning the patient to an anticoagulated state as soon as feasible and safe prevents thrombotic complications. Finally, an EMCREG-International Severe Bleeding Consensus Panel algorithm for the approach to management of patients with life-threatening oral anticoagulant-associated bleeding is provided for the clinician and can be expanded in size for use in a treatment area such as the emergency department or critical care unit.

Cerebral amyloid angiopathy and atrial fibrillation: a dangerous union

Intracranial hemorrhage (ICH) is the major complication of oral anticoagulant therapy. Cerebral amyloid angiopathy (CAA) is an age-related disease characterized by the pathological deposition of β-amyloid protein in leptomeningeal and cortical cerebral vessels. Such vascular alterations expose to the risk of spontaneous vascular rupture. The main clinical manifestations are represented by ICH, cognitive decline and transient focal neurological episodes (TFNE). In the patient subgroup with TFNE, a misdiagnosis with transient ischemic attack may have catastrophic consequences, resulting in a significant increase in the risk of spontaneous ICH within weeks after clinical onset, with potentially devastating consequences if anticoagulant therapy is started.The prevention of bleeding complications related to CAA is based on disease knowledge. This is particularly relevant because non-pharmacological treatment options, including percutaneous left atrial appendage occlusion, are emerging as an alternative to traditional anticoagulant therapies in patients at high bleeding risk.

Direct-Acting Oral Anticoagulants and Warfarin-Associated Intracerebral Hemorrhage Protocol Reduces Timing of Door to Correction Interventions.

Intracerebral hemorrhage (ICH) is a life-threatening complication of oral anticoagulant therapy that sometimes results in hematoma expansion after onset. Our facility did not have a standardized process for treating oral anticoagulant-associated ICH; this resulted in lag times from order to reversal agent administration. The aim of this study was to examine the impact of a rapid anticoagulant reversal protocol, combined with warfarin and direct-acting oral anticoagulant therapy, in decreasing door to first intervention times. This study used a retrospective quality assessment research approach in examining an oral anticoagulant reversal protocol to compare the control and intervention groups. Phytonadione was the first intervention treatment for most study participants diagnosed with warfarin-associated ICH with an international normalized ratio greater than 1.4. Factor IX was the first intervention treatment for all but one study participant with DOAC-associated ICH. Findings were statistically significant (P < .05) for door to first intervention treatments. Door to phytonadione in minutes decreased from 232.7 (SD, 199.4) to posttest findings of 111.4 (SD, 64.6). Door to factor IX in minutes decreased from 183.9 (SD, 230.2) to posttest findings of 116.6 (SD, 69.1). Study findings support the hypothesis that the new protocol was associated with lower door-to-treatment times for eligible patients.

Spontaneous Spinal Haemorrhage as a Complication of Oral Anticoagulant Therapy: A Case Report and Literature Review.

Spinal cord haematoma, or haematomyelia, is a rare condition caused by several unusual disease processes. Traumatic events, such as spinal cord injury and surgery or procedures involving the spinal cord, are the most important causes of spinal cord haematoma. Rarely, it is associated with anticoagulation therapy. Irrespective of cause, spinal cord haematoma is considered a neurosurgical emergency and must be treated promptly in order to prevent neurological sequelae. The authors describe the case of a 69-year-old patient taking warfarin in the therapeutic range for a mechanic mitral valve, who developed chest pain with cervical and dorsal radiation, and experienced sudden paraparesis of the limbs. A CT of the spine confirmed haematomyelia. A high index of suspicion, prompt recognition and immediate intervention are essential to prevent major morbidity and mortality from intraspinal haemorrhage.LEARNING POINTSThis article reports an unusual presentation of spontaneous spinal haematoma, imposing the careful elaboration of differential diagnoses, which is very important in internal medicine.The description of this low-incidence case allows the scientific community to assist in approaching patients with similar symptoms.The lack of studies about the etiology and treatment of spontaneous spinal haematoma underlines the need for further studies and research in the area in order to increase the scientific evidence on the approach of these patients.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown.&#x0D; Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin.&#x0D; Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown.&#x0D; Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin.&#x0D; Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.

Re-Initiation of Oral-Anticoagulants in Survivors of Hemorrhagic Stroke

Abstract Intra-cerebral hemorrhage (ICH) is the most feared and the deadliest complication of oral anticoagulant therapy, i.e. warfarin (Coumadin). After such an occurrence, clinicians wonder whether their patients should resume anticoagulant therapy. The decisions to reverse and re-initiate anticoagulation hinge on the phase of stroke as the risk of thromboembolism outweighs risk of bleeding in the chronic phase. Hence in the short term, most patients with ICH will benefit from acute reversal of anticoagulation, followed by gradual reinstitution of prophylactic-dose anticoagulation after first 24–72 h. The underlying cause of stroke should guide the long-term management.

Complications of Oral Anticoagulant Therapy in over 65 Years, a Case Report

Case description: Woman, 79 years old. Medical history: hypertension, Atrial fibrillation (AF) permanent treated with acenocoumarol and mitral insufficiency. Barthel 90, Lowton-Brody. 2. The patient came to the emergency room for rib pain (musculoskeletal) in last two weeks, without other symptoms. We initiated analgesia and the patient was discharged. She came back with new symptoms: epistaxis and dyspnea. Exploration and complementary tests: cardio-pulmonary auscultation arrhythmic tones with sternal border systolic murmur left, crakling sounds in the lungs, with decreased breath sounds. Chest x-ray: right hilar mass with right pleural thickening, and diffuse bilateral infiltration. CBC: hemoglobin 7.9 g/dl (First: 11.6 g/dl), WBC 11.57x10l. Biochemistry: PCR 72.90 mg/l, urea 85 mg/l. Coagulation: INR undetermined, activity prothrombin &lt;12.5%. Diagnosis: bilateral alveolar hemorrhage. Diagnosis Differential: bilateral alveolar hemorrhage, bilateral pneumonia, heart failure congestive (Acute Lung Edema). Conclusion: 0.5% of the population uses oral anticoagulants, between 6.8-11.1% by FA an INR&gt;, increases the risk of bleeding. This is a patient with multimorbidity, moderately dependent, with poor treatment compliance and anticoagulation control. Given these data (anemia, no signs of infection or heart failure), and the test results, we opted for the first possibility alveolar hemorrhage diagnosed.

Complications of Oral Anticoagulant Therapy in over 65 Years, a Case Report

Case description: Woman, 79 years old. Medical history: hypertension, Atrial fibrillation (AF) permanent treated with acenocoumarol and mitral insufficiency. Barthel 90, Lowton-Brody. 2. The patient came to the emergency room for rib pain (musculoskeletal) in last two weeks, without other symptoms. We initiated analgesia and the patient was discharged. She came back with new symptoms: epistaxis and dyspnea. Exploration and complementary tests: cardio-pulmonary auscultation arrhythmic tones with sternal border systolic murmur left, crakling sounds in the lungs, with decreased breath sounds. Chest x-ray: right hilar mass with right pleural thickening, and diffuse bilateral infiltration. CBC: hemoglobin 7.9 g/dl (First: 11.6 g/dl), WBC 11.57x10l. Biochemistry: PCR 72.90 mg/l, urea 85 mg/l. Coagulation: INR undetermined, activity prothrombin &lt;12.5%. Diagnosis: bilateral alveolar hemorrhage. Diagnosis Differential: bilateral alveolar hemorrhage, bilateral pneumonia, heart failure congestive (Acute Lung Edema). Conclusion: 0.5% of the population uses oral anticoagulants, between 6.8-11.1% by FA an INR&gt;, increases the risk of bleeding. This is a patient with multimorbidity, moderately dependent, with poor treatment compliance and anticoagulation control. Given these data (anemia, no signs of infection or heart failure), and the test results, we opted for the first possibility alveolar hemorrhage diagnosed.

C0523: Venous Thromboembolism in Special Populations-Findings from the Riete Registry

Background: Bleeding is a common and feared complication of oral anticoagulant therapy. Several prediction models have been recently developed, but there is a lack of evidence in patients with venous thromboembolism (VTE). The aim of this study was to validate currently available bleeding risk scores during long-term oral anticoagulation for VTE. Methods: We retrospectively included adult patients on vitamin K antagonists (VKAs) for VTE secondary prevention, followed by five Italian Anticoagulation Clinics (Cuneo, Livorno, Mantova, Napoli, Varese), between January 2010 and August 2012. All bleeding events were classified as major bleeding (MB) or clinically-relevant-nonmajor-bleeding (CRNMB). Results: 681 patients were included (median age 63 years; 52.0% female). During a mean follow-up of 8.82 (±3.59) months, 50 bleeding events occurred (13 MB and 37 CRNMB), for an overall bleeding incidence of 9.99/100 patient-years. The rate of bleeding was higher in the first three months of treatment (15.86/100 patient-years) than afterwards (7.13/100 patient-years). The HASBLED showed the best predictive value for bleeding complications during the first three months of treatment (AUC 0.68, 95%CI 0.59– 0.78), while only the ACCP showed a modest predictive value after the initial three months (AUC 0.61, 95%CI 0.51–0.72). These two scores had also the highest sensitivity and the highest negative predictive value. Conclusions: Currently available bleeding risk scores had only a modest predictive value for patients with VTE. Future studies should aim at the creation of a new prediction rule, in order to better define the risk of bleeding of VTE patients.

Warfarin untargeted metabolomics study identifies novel procoagulant ethanolamide plasma lipids

Warfarin untargeted metabolomics study identifies novel procoagulant ethanolamide plasma lipids

Poor predictive value of contemporary bleeding risk scores during long-term treatment of venous thromboembolism. A multicentre retrospective cohort study.

Bleeding is a common and feared complication of oral anticoagulant therapy. Several prediction models have been recently developed, but there is a lack of evidence in patients with venous thromboembolism (VTE). The aim of this study was to validate currently available bleeding risk scores during long-term oral anticoagulation for VTE. We retrospectively included adult patients on vitamin K antagonists for VTE secondary prevention, followed by five Italian Anticoagulation Clinics (Cuneo, Livorno, Mantova, Napoli, Varese), between January 2010 and August 2012. All bleeding events were classified as major bleeding (MB) or clinically-relevant-non-major-bleeding (CRNMB). A total of 681 patients were included (median age 63 years; 52.0% female). During a mean follow-up of 8.82 (± 3.59) months, 50 bleeding events occurred (13 MB and 37 CRNMB), for an overall bleeding incidence of 9.99/100 patient-years. The rate of bleeding was higher in the first three months of treatment (15.86/100 patient-years) than afterwards (7.13/100 patient-years). The HAS-BLED showed the best predictive value for bleeding complications during the first three months of treatment (area under the curve [AUC] 0.68, 95% confidence interval [CI] 0.59-0.78), while only the ACCP score showed a modest predictive value after the initial three months (AUC 0.61, 95%CI 0.51-0.72). These two scores had also the highest sensitivity and the highest negative predictive value. None of the scores predicted MB better than chance. Currently available bleeding risk scores had only a modest predictive value for patients with VTE. Future studies should aim at the creation of a new prediction rule, in order to better define the risk of bleeding of VTE patients.

Koncept modifikacije doze oralnih antikoagulantnih lekova radi smanjenja rizika od hemoragijskih komplikacija - kako odabrati pravu dozu?

Variable intensity of anticoagulant effect with oral vitamin K antagonists (VKA), which may be aggravated by diet, alcohol consumption and concomitant drug therapy necessitates regular laboratory monitoring of anticoagulant intensity and VKA dose adjustments. Frequent oscillations of the International Normalized Ratio (INR) values outside the therapeutic range and resultant low Time in therapeutic Range (TTR ) increase the risk of both thromboembolic and bleeding events, and many patients eventually stop taking VKA after some time. Those were the reasons that prompted the search for alternative oral anticoagulant drugs. It was never about efficacy, but a more convenient (and possibly safer) therapy has been searched for, which would allow for a fixed dosing without the need for routine laboratory monitoring of anticoagulant effect due to stable, dose-dependent anticoagulation. Now it seems that these aims have been achieved, at least partly. Since recently, we have oral anticoagulant drugs which are much safer than VKAs, particularly in terms of significantly reduced risk of the most serious, often fatal haemorrhagic complication of oral anticoagulant therapy - intracerebral haemorrhage. Efficacy of these 'new' drugs - non-vitamin K oral anticoagulants (NOAC s) is more or less similar to the efficacy of VKAs, with no food interaction and fewer clinically relevant interactions with other drugs as compared to warfarin and other VKAs. However, with respect to the dosing of NOAC s and the need for blood analyses in patients taking a NOAC , available data suggest that we might not have not found the 'one size fits all' jacket yet. In essence, all randomized clinical trials comparing the efficacy and safety of oral direct factor Xa inhibitors versus warfarin for stroke prevention in AF (ROC KET-AF - rivaroxaban, ARI STOTL E - apixaban and ENGAG E-AF - edoxaban) also tested the NOAC dose modifications in relation to certain clinical characteristics of the patient, and the principles of dose modifications were pre-defined by the study protocol. In contrast, the RE-LY study tested efficacy and safety of the two doses of oral direct thrombin inhibitor dabigatran (110 mg or 150mg twice daily) with no dose modification, irrespective of the patient characteristics. In this commentary we discuss the principles of NOAC s individual dose selection for stroke prevention in AF in the context of recently published data.

Clinical management of spontaneous intracranial haemorrhage associated with oral anticoagulants: a case series

Introduction: Intracranial haemorrhage (ICH) is associated with high mortality and morbidity, and for this reason it is the most feared complication of oral anticoagulant therapy (OAT). Recommendations are available for the immediate reversal of OAT, but these measures are not always used uniformly and rapidly. The aim of this study was to critically review the treatment of spontaneous OAT-related ICH in our hospital. Materials and methods: We retrospectively analyzed the medical records of patients admitted to our ward between January 2006 and January 2010 for spontaneous OAT-related ICH. Results: In the analyzed period, 15 patients were hospitalized for OAT-related ICH (supratentorial in 66.5%, infratentorial in 20%, acute subdural hematoma in 13.5%). In 66.5% of the patients, the INR on arrival was within the therapeutic range. In 60% of the cases, the Glasgow Coma Scale (GCS) on arrival was &gt; 8/15. Three-factor prothrombin complex concentrate (PCC) was administered in 80% of the cases, and 30% of patients received fresh frozen plasma (FFP) and recombinant activated factor VII (FVIIra). One patient received PCC plus PFC, and another received PCC with FVIIra. FFP alone was used in 13.5% of the patients. All of the patients received intravenously administered vitamin K1. Treatment was started in the Emergency Room in 33.5% of the cases; in the other 66.5% it began on our ward. In 66.5% of the patients, the treatment was effective in reversing OATwithin 8 hours. In 2 cases, the hematoma was surgically evacuated, and the patients survived. Total mortality for OAT-related ICH was 46.5% (32.9% in non-OAT-related ICH). In 71.5% of the patients with OAT-related haemorrhages, death occurred within 48 hours of arrival. Sixty percent of the patients with ICH &gt; 60 cm3 (20% in patients with ICH &lt; 60 cm3) and 100% of those with GCS &lt; 7/15 died. For survivors, the median modified Rankin Scale at discharge was 3. All survivors were still alive at 3 months after discharge. Conclusions: Our study shows that in ICH associated with OAT, mortality is related to the size of the hematoma and to the GCS. Our study confirms that treatment of OAT-related ICH varies and is sometimes delayed. Management protocols for ICH-OATshould be implemented in clinical settings.

Spontaneous sublingual and intramural small-bowel hematoma in a patient on oral anticoagulation

Spontaneous sublingual hematoma and intramural small bowel hematoma are rare and serious complications of anticoagulant therapy. Though previously reported individually, there has been no previous report of the same two complications occurring in a single patient. A 71-year-old Caucasian man, who was on warfarin for atrial fibrillation, presented with difficulty in swallowing due to a sublingual hematoma. He was observed in our intensive care unit, his warfarin was held and he recovered with conservative management. He represented two months later with a two day history of abdominal pain and distension. An abdominopelvic computed tomography (CT) scan now showed small bowel obstruction due to intramural small bowel hematoma and haemorrhagic ascites. Again, this was treated expectantly with a good outcome. In conclusion, life threatening haemorrhagic complications of oral anticoagulant therapy can recur. Conservative treatment is successful in most cases, but an accurate diagnosis is mandatory to avoid unnecessary surgery. CT scan is the investigation of choice for the diagnosis of suspected haemorrhagic complications of over coagulation.

Oral anticoagulation related intracerebral hemorrhage: more questions than answers

Intracranial hemorrhage (ICH) is the most feared and devastating complication of oral anticoagulant therapy. When an ICH occurs, the patient’s situation hinges on the balance between how great is the embolic risk while not receiving anticoagulants, and how big is the threat of the hemorrhage if the anticoagulant effect is not reversed promptly. Although several studies which compared the use of different reversal agents failed to demonstrate any improvement in prognosis and survival, at the present moment the consensus seem to be that anticoagulation should be rapidly reversed after an ICH. The second question to be answered is whether and when should be oral anticoagulation treatment restarted. Although the risk of thromboembolism in patients off anticoagulation seems to be higher than the risk of ICH recurrence, there is a marked paucity of prospective large studies on the real risk of ICH recurrence when OAC is resumed, paucity that probably emphasizes the ethical challenge of prescribing patients a medication to which they have an apparent contraindication. The little evidence available suggests that the optimal time for resumption is between 10 days and 30 weeks.

A Case of Warfarin-Induced Intramural Hematoma Diagnosed by Double-Balloon Enteroscopy

Although bleeding is a major complication of oral anticoagulant therapy, warfarin-induced spontaneous intramural hematoma of the small bowel is a very rare complication. The clinical features of spontaneous intramural hematoma vary from mild abdominal pain to panperitonitis due to bowel perforation. Because spontaneous intramural hematoma can proceed to a life threatening situation, early diagnosis is of vital importance. Although there are a number of radiologic diagnostic tools available including abdominal ultrasonography and computed tomography, confirmation of the diagnosis through direct visualization of the involved bowel mucosa is very helpful. Direct confirmation of warfarin-induced spontaneous intramural hematoma of the small bowel is possible using double-balloon enteroscopy. We report a case of warfarin-induced spontaneous intramural hematoma with a review of the relevant literature. (Intest Res 2011;9:162-165)