Anticoagulant and intracerebral haematomas

Case report

The patient was a 70-year old Caucasian who was found collapsed in his chair. He complained of headaches and on examination, he was drowsy; opening eyes to speech, obeying commands and was broadly orientated. His past medical history included angina and atrial fibrillation for which he was on Warfarin and Digoxin. The ECG demonstrated atrial fibrillation with occasional ventricular ectopics. He was also hypertensive and taking appropriate medication. CT brain scan revealed a large left cerebellar haematoma with evidence of early hydrocephalus. An emergency external ventricular drain was inserted but the haematoma was treated conservatively. He made an eventful recovery and was discharged home after a month in hospital. On discharge to the referring hospital, he was much better and had no apparent disability. His Warfarin had been omitted during his stay in hospital but this was restarted at the other hospital. Five months later the patient represented in coma due to a large intracerebral haematoma, which had decompressed into the ventricles and the subarachnoid space. He was in poor grade when he was admitted, withdrawing to pain. Cerebral angiography ruled out an aneurysm or a vascular lesion. The poor prognosis was explained to his family and he died 9 days following the admission.

Discussion:

ICH accounts for 15% of strokes. Its mechanisms include hypertension, cerebral amyloid angiopathy, rupture of vascular malformations, bleeding into primary or metastatic brain tumours, coagulopathies (due to the use of anticoagulants and thrombolytic agents), sympathomimetic drug effect (amphetamines, phenylpropanolamine, and cocaine), and vasculitis (1). Anticoagulants are highly essential drugs in patients with atrial fibrillation but there is a risk of stroke.

The issue of stopping anticoagulant in patients with ICH is still largely unresolved. Many will reverse the anticoagulant at the risk of cardiac complications. The duration of stoppage of Warfarin is also largely unknown. In this patient, the Warfarin was reintroduced after the initial admission (the patient was in hospital for I month following the initial bleed). He rebled again on Warfarin and this proved to be fatal. Rebleeding after an initial stroke has been discussed previously (3). In a prospective study, the prognostic value of clinical characteristics and CT scan findings in 50 patients of intracerebral haemorrhage (ICH) has been examined. At the end of the follow up period 34% of the patients died, 36% were dependent on outside help for daily living while 30% were capable of independent existence. Age of more than 60 yrs, Glasgow Coma Scale (GCS) Score of 6 or less (in a modified Scale of 10) at the time of admission, ICH volume greater than 30 ml., midline shift in CT scan of more than 3 mm and presence of intraventricular haemorrhage (IVH) and hydrocephalus had an adverse impact on outcome. Young age, GCS score of more than 8, ICH volume of less than 20 ml, presence of lobar haemorrhage and absence of IVH/hydrocephalus were associated with relatively favourable outcome (2). Warfarin therapy is also a significant risk and an important factor in rebleeding as demonstrated in this case.

References:

1. Kase Cs: Intracerebral haemorrhage. [Review] [90 refs]. Baillieres Clinical Neurology 4:247-278, 1995.
2. Mitra D, Das Sk, Ganguly Pk, Roy Tn, Maity B, Munshi Ak: Prognostic factors in intracerebral haemorrhage. Journal of the Association of Physicians of India 43:602-604, 1995.
3. Passero S, Burgalassi L, D'Andrea P, Battistini N: Recurrence of Bleeding in Patients with Primary Intracerebral Haemorrhage. Stroke 26:1189-1192, 1995.

Images

The initial CT scan of the admission earlier in the year shows the left sided cerebellar clot and obstructive hydrocephalus. He was managed with an external ventricular drain.

CT of the second admission showing a fatal ICH with intraventricular blood. Emergency angiography was performed to reveal any underlying cause. This was normal as shown below.

Created by B I Ogungbo in September 2002. Modified January 2008. ©