颅内静脉窦血栓形成合并脑出血的临床分析

目的探讨Solitaire AB支架取栓联合局部溶栓治疗颅内静脉窦血栓形成(CVST)合并脑出血的临床疗效。方法回顾性研究29例CVST合并脑出血病人病例资料,血管内介入治疗(抗凝+Solitaire AB支架取栓+局部溶栓) 14例,单纯抗凝治疗15例,对比两组病人的临床疗效及预后。结果介入治疗组病人的临床疗效、血管再通情况、预后良好情况均优于单纯抗凝治疗组,存在统计学差异(均P 0.05)。结论应用Solitaire AB支架取栓联合局部溶栓治疗CVST合并脑出血能有效缓解病人临床症状,改善预后结果。     

血管内治疗与单纯抗凝治疗颅内静脉(窦)血栓的疗效对比分析

目的 比较血管内治疗与单纯抗凝治疗颅内静脉(窦)血栓(CYST)的疗效. 方法 哈尔滨市第一医院神经外科自1998年1月至2008年12月收治42例CVST患者,其中21例应用单纯抗凝治疗,21例应用血管内治疗.治疗后3 d观察患者颅内压(ICP)下降情况,治疗前、后(3 d及3、6、12个月)通过目测类比法(VAS)检测患者的头痛程度.结果 治疗后患者ICP均下降,血管内治疗组除1例患者ICP由术前620 mm H_2O降至410 mm H_2O,其余患者ICP基本稳定在200～260mmH_2O.单纯抗凝治疗组患者1例ICP降至350mmH_2O,5例ICP在400mmH_2O以上,脑疝死亡1例.治疗后3 d、3个月时血管内治疗组和单纯抗凝治疗组患者VAS评分(3 d:8.1±1.6vs3.5±1.5:3个月:4.9±1.4 vs 2.2±1.3)差异均有统计学意义(P<0.05).结论 应用血管内治疗CVST能够较快的缓解患者的主要症状并改善患者的预后,较为可靠和安全.     

华法令预防心房纤颤患者并发脑梗死的疗效观察

目的 观察华法令与阿司匹林联用与单用阿司匹林在预防心房纤颤(AF)患者并发脑梗死的疗效差距,探讨心房纤颤患者长期服用华法令的有效性、安全性与可行性.方法 80例心房纤颤患者随机分为华法令组40例与阿司匹林组40例,2组均予拜阿司匹灵100mg/d早餐后顿服,华法令组加用华法令晚饭后口服,起始剂量为2mg/d,1周后若INR(凝血酶原国际标准化比值)未达到2.0～3.0,逐步增加华法令剂量使INR值在2.0～3.0之间.随访3年,比较2组患者脑梗死的发生率、病死率、总病死率(包括脑梗死及非脑梗死事件)、出血事件发生率、严重出血发生率、轻度出血发生率.结果 华法令组和阿司匹林组脑梗死发生分别为2例(5.0%)和6例(15.0%),2组比较,P＜0.01;华法令组和阿司匹林组脑梗死患者死亡分别为0例(0%)和2例(5.0%),2组比较,P＜0.01;总死亡华法令组和阿司匹林组分别为2例(5.0%)和4例(10.0%),P＜0.01;2组发生严重出血均为0例,P＞0.05;华法令组轻度出血发生6例(15.0%),其中皮下出血4例,阿司匹林组发生1例(2.5%),华法令组高于阿司匹林组,P＜0.01,但给予调整剂量后症状消失,不影响继续用药.结论 AF患者在常规使用阿司匹林的基础上加用抗凝药物华法令长期口服,可使脑梗死的发生率、脑梗死患者病死率、总病死率明显降低,在合理监测的情况下并未发生严重出血.建议在能定期监测INR值的AF患者中推广使用,以使更多AF患者受益.     

低分子肝素加华法令对TIA患者的近期疗效观察

目的 :研究 TIA用低分子肝素加华法令的抗凝治疗价值。方法 :低分子肝素 5 0 0 0 AXa IU ,每 12小时一次皮下注射 ,同时服用华法令 ,其剂量最初为 4～ 6毫克 ,合用三天 ,停用低分子肝素。以后用华法令维持抗凝治疗 ,根据凝血酶原时间 ,活动度 ,INR调整华法令用量 ,至抗凝状态稳定后 ,用华法令维持 2～ 3个月以稳定抗凝治疗。结果 :治疗组 35例 ,经低分子肝素加华令抗凝治疗 ,32例 TIA停止发作 ,2例继续发作 ,1例发生脑梗死。对照组 :35例 11例 TIA停止发作 ,10例继续发作 ,14例发生脑梗死。二组在疗效上有显著性差异 ,在脑、消化道出血方面 ,无差异 ,在局部皮肤及牙龈出血方面 ,治疗组高于对照组 ,但临床不影响疗效。结论 :对 TIA患者用低分子肝素加华法令的抗凝治疗有效。     

脑出血早期应用丹参治疗的疗效观察

目的 观察脑出血早期应用丹参治疗的临床疗效.方法 高血压脑出血患者61例,随机分为治疗组和对照组,2组均给予传统治疗,治疗组在此基础上于发病24h后加用丹参治疗.结果 治疗组和对照组的总有效率分别为90.0%和64.5%(P＜0.01),治疗第28d血肿体积分别为(7.12±1.26)ml,(15.67±1.22)ml,(P＜0.01);灶周最大水肿面积分别为(0.92±0.01)cm2 、(1.66±0.04) cm2(P＜0.01).结论 早期应用丹参治疗脑出血疗效确切,能促进血肿吸收,缩短脑水肿消失时间.     

心房颤动患者口服华法林相关脑出血危险因素分析

目的分析心房颤动(AF)患者口服华法林相关脑出血危险因素及预后情况,从而减低华法林相关脑出血(WAICH)的发生率与死亡率。方法本研究通过哈尔滨医科大学附属第一医院电子病历系统查找从2015年1月至2017年12月在神经内科、外科住院AF患者WAICH患者20例和AF口服华法林无颅内出血患者30例为调查对象。记录患者基本信息、既往史、危险因素、实验室检查、出院转归等方面进行整理。同样方法搜集无出血组资料。对上述资料进行SAS9.4软件统计学分析。结果经分析,出血组与无出血组在高血压病、缺血卒中史、出血史、治疗时间≤1年、血浆凝血酶原时间(PT)为30.36±22.53、活化部分凝血活酶时间(APTT)为43.88±17.75、国际标准化比值(INR)2.93±1.80、INR异变率、合并使用抗血小板药物、HAS-BLED评分为3.30±0.73有统计学差异(P <0.05),将上述单因素有意义的变量放入多因素Logistic模型中,采用逐步回归,结果表明PT,APTT,治疗时间长短是独立因素。结论高血压病、缺血卒中史、出血史、PT升高、APTT升高、INR增高、有INR异变率、治疗时间≤1年、合并应用抗血小板药物患者、HAS-BLED评分高是非瓣膜房颤(NVAF)患者口服华法林相关脑出血的危险因素;PT增高,APTT增高,治疗时间≤1年为NVAF口服华法林致WAICH的独立危险因素。     

经颅超声联合溶栓治疗对急性缺血性脑卒中患者血管再通的作用

目的探讨经颅超声联合溶栓治疗对于急性缺血性脑卒中患者血管再通的作用。方法收治的40例急性缺血性脑卒中患者随机分为经颅超声组和溶栓治疗组,2组患者均给予尿激酶溶栓治疗,经颅超声组患者在此基础上给予经颅超声治疗,采用经颅多普勒超声、美国国立卫生所脑卒中量表(NIHSS)于治疗前、治疗后2h、治疗后24h评估患者,并于治疗后3个月评价患者预后良好改良Rankin评分≤2分的发生率,治疗后采用CT评估患者并发脑出血情况。结果经颅超声组患者治疗后2h、24h血管再通率分别为45.0%、55.0%,显著高于溶栓治疗组的15.0%、20.0%再通率(P0.05);治疗后2h、治疗后24h经颅超声组NIHSS评分分别为(10.6±2.8)分、(10.1±2.6)分,显著低于溶栓治疗组(13.9±3.3)分、(13.1±3.2)分的NIHSS评分(P0.05);经颅超声组预后良好发生率为65.0%,显著高于溶栓治疗组20%(P0.05);2组患者脑出血发生率差异无统计学意义(P0.05)。结论在传统尿激酶溶栓治疗的基础上给予经颅脉冲超声治疗,能够显著提高血管再通率,改善患者预后,值得临床推广应用。     

高血压脑出血神经内镜微创手术与开颅血肿清除术的临床比较分析

目的比较高血压脑出血神经内镜微创手术与开颅血肿清除术的临床特点与疗效。方法收集77例高血压脑出血手术患者的手术时间、手术失血量和GCS评分等临床资料,根据其治疗方案分为神经内镜微创手术组与开颅血肿清除术组,以第3个月GOS评分作为预后指标。采用SPSS10.0,比较两种手术方式手术时间、手术失血量、血肿清除率及其GOS预后评分的差别,观察、分析手术疗效。结果神经内镜微创手术组与开颅血肿清除术组两组病例术前临床资料无明显差异(P值均0.05)。在手术时间上,神经内镜组平均手术时间(1.6±0.5)h,开颅血肿清除术组平均手术时间(4.6±1.8)h(P0.01);在手术失血量上,神经内镜微创组平均手术失血量33.2±6.2mL,开颅血肿清除术组平均手术失血量(406.4±305.6)mL(P0.01);在血肿清除率上,神经内镜组脑内血肿平均清除率为88.6%±6.2%,开颅组平均血肿清除率为69.4%±27.9%(P0.05);在GOS预后方面,在26例术后随访满3月神经内镜组患者中恢复良好6例,轻度残疾10例,重度残疾5例,植物状态4例,死亡1例(家属放弃治疗后院内死亡)。开颅组49例患者中,恢复良好7例,轻度残疾8例,重度残疾13例,植物状态12例,死亡6例。3例因经济原因在术后放弃治疗脱失。神经内镜微创组患者预后优于开颅组患者预后(P0.05)。结论神经内镜高血压脑出血手术是一种更具有微创、高效、快速、出血少等特点的高血压脑出血手术方法。     

脑静脉窦血栓形成伴颅内出血的治疗分析

目的 对比单纯抗凝和机械取栓联合局部溶栓治疗颅内静脉窦血栓形成(CVST)伴颅内出血患者的效果。方法 回顾性分析2014年6月-2018年6月武汉大学中南医院神经内科收治的28例CVST伴颅内出血患者的病例资料,根据其治疗方式分为单纯抗凝组(12例)和机械取栓组(机械取栓+局部溶栓+抗凝组16例),比较2组患者临床疗效、再通情况及预后。结果 机械取栓组的临床疗效、血管再通情况及预后均优于单纯抗凝组(P均<0.05),单纯抗凝组治疗后均未发现新发出血灶,机械取栓组仅有1例术后出现阴道出血。结论 对于合并有颅内出血的CVST患者,机械取栓联合局部溶栓治疗能有效促进静脉血流的恢复,缓解临床症状和改善预后。     

院前急救对高血压脑出血患者预后的影响

目的观察院前急救对高血压脑出血患者预后的影响。方法选取2012-04—2014-02于我院接受治疗的184例高血压脑出血患者为研究对象,以有无院前急救为根据将患者分为对照组以及观察组,每组92例。对比2组病死率、并发症情况、临床疗效以及有效转运时间。结果对照组患者的有效转运时间(1.27±0.27)h,观察组为(0.95±0.13)h,观察组有效运转时间显著优于对照组,差异有统计学意义(P0.05)。观察组总有效率89.13%,显著高于对照组的67.39%,差异有统计学意义(P0.05)。观察组发症发生率15.21%,显著低于对照组的30.43%,差异有统计学意义(P0.05)。观察组6例死亡,病死率6.52%;对照组16例死亡,病死率17.39%,2组比较差异有统计学意义(P0.05)。结论院内急救对高血压脑出血患者的预后有较大影响,针对患者进行院前急救干预可以帮助患者争取抢救时间,改善临床疗效,降低并发症发生率,值得临床推广。     

口服华法令合并外伤性颅内出血患者的围手术期处理

目的 探讨长期口服抗凝药物华法令合并外伤性颅内出血患者的围手术期处理措施.方法 10例此类患者入院后给予维生素K、新鲜冰冻血浆和凝血酶原复合物来逆转患者的抗凝状态.9例患者接受开颅手术清除颅内血肿.3例患者术后接受预防剂量的低分子肝素的治疗.结果 术后所有患者均存活,其中5例恢复良好,3例遗留不同程度的偏瘫或失语症状,2例患者术后长期植物状态生存.结论 伤后、术前迅速纠正凝血指标参数至关重要,与患者预后密切相关.

Abstract：

Objective To study the perioperative management in the treatment of traumatic intracranial hemorrhage in patients with pretraumatic anticoagulation therapy of oral warfarin. Method 10 patients of traumatic intracranial hemorrhage with pretraumatic anticoagulation therapy of oral warfarin received vitamin K, FFP and PCC treatment to reverse the anticoagulation condition after admission. 9 patients underwent the operation for evacuation of intracranial hematoma. Low - molecular - weight heparin was administered as prophylactic dose in 3 patients. Results All patients in this group were survival. 5 of them get well recovery. 3 of them remained different degrees of hemiplegia or aphasia and 2 patient got vegetative state after operation. Conclusions Pre - operative normalization of coagulation capacity is of utmost importance in patients with head injury and plays an important role in the prognosis of patients.     

The effects of low-intensity warfarin on coagulation activation in patients with antiphospholipid antibodies and systemic lupus erythematosus.

The optimal intensity of oral anticoagulant therapy for the prevention of thromboembolism in patients with antiphospholipid antibodies (APLA) and systemic lupus erythematosus is controversial. Retrospective studies have suggested that patients with APLA are resistant to oral anticoagulant therapy, with a targeted International Normalization Ratio (INR) of 2.0 to 3.0, and that a higher intensity of anticoagulation (INR: 2.6 to 4.5) is required to prevent recurrent thromboembolism. To investigate if patients with APLA are resistant to the anticoagulant effect of low intensities of warfarin therapy, we performed a randomized trial in which 21 patients with APLA and systemic lupus erythematosus were allocated to receive one of three intensities of warfarin (INR: 1.1 to 1.4, 1.5 to 1.9 or 2.0 to 2.5) or placebo for four months. The main outcome was the effect of each intensity of warfarin therapy on prothrombin fragment 1+2 level (F1+2), that was used as a marker of coagulation activation. When F1+2 levels in patients allocated to the three warfarin intensities were compared to F1+2 levels in the placebo group, there was a statistically significant decrease (p<0.05) in the patient group receiving warfarin with a targeted INR of 2.0 to 2.5 at two, three and four months, and in the patient group with a targeted of INR 1.5 to 1.9 at three months. We conclude that in patients with APLA and systemic lupus erythematosus, warfarin therapy, with a targeted INR of 2.0 to 2.5, is effective in suppressing coagulation activation, and therefore, might be effective in preventing thromboembolism.     

Oral anticoagulation for cerebral ischemia of arterial origin: high initial bleeding risk.

BACKGROUND: The use of oral anticoagulant therapy for the prevention of arterial thromboembolism in patients who have had ischemic stroke is controversial. Coumarins may increase the bleeding risk in patients with cerebral ischemia of arterial origin. OBJECTIVES: 1) To calculate incidence rates of bleeding and thromboembolic events in patients with noncardiac cerebral ischemia who were treated routinely in an anticoagulation clinic. 2) To assess which factors contribute to the occurrence of events. 3) To determine the optimal intensity of oral anticoagulant therapy in these patients. METHODS: The authors studied all patients treated for noncardiac cerebral ischemia at the Leiden anticoagulation clinic between 1993 and 1998. Outcome events were major hemorrhage, major arterial thromboembolism, and death. RESULTS: The authors observed 356 patients for 644 patient-years. The incidence of major hemorrhage was 3.9 per 100 patient-years (95% CI, 2.5 to 5.7) and that of thromboembolism was 3.0 per 100 patient-years (95% CI, 1.8 to 4.6). The incidence of hemorrhage varied with the duration of treatment (relative risk [RR] of the first versus the second half-year, 3.8; 95% CI, 1.9 to 7.6), age (RR for age >65 years, 3.7; 95% CI, 1.1 to 12.3), and the intensity of oral anticoagulation (RR, 1.8 for each 0.5 international normalized ratio [INR] unit increase; 95% CI, 1.5 to 2.3). The optimal intensity of oral anticoagulant therapy was 2.5 to 3.5 INR; the best target value was 3.0 INR. CONCLUSION: The risk of hemorrhage with anticoagulant therapy is high in patients with ischemic stroke of arterial origin but is mainly confined to early use and elderly patients.     

Warfarin-induced bleeding complications - clinical presentation and therapeutic options

Acute bleeding during oral anticoagulant therapy is a major challenge in medicine -with millions of patients receiving oral anticoagulant therapy worldwide, the frequency of severe bleeding episodes ranges from 2% to 13%, according to clinical trial data. The major risk associated with the use of oral anticoagulants is haemorrhage, which might be severe or even life-threatening. Treatment decisions for the reversal of oral anti-coagulation (OAC) depend on factors such as urgency of the situation, as determined by the international normalised ratios (INR), location and seventy of bleeding, and indication for anticoagulation. Currently available therapeutic options for the reversal of OAC include vitamin K for non-emergency situations and fresh frozen plasma (FFP) and coagulation factor concentrates such as prothrombin complex concentrate (PCC) for urgent situations. Complete and rapid reversal of warfarin-induced bleeding can be achieved more successfully with PCC than with FFP. In addition, PCC is associated with a more rapid normalisation of the INR and a better clinical outcome due to the balanced ratio of four vitamin-K-dependent clotting factors plus the coagulation inhibitors protein C and Protein S. PCC products containing four factors are the preferred option for the emergency reversal of OAC, according to some clinical treatment guidelines. Other advantages of PCC over FFP include smaller infusion volumes, no blood group testing and virus-inactivated blood product.     

The influence of fluid intake on stroke recurrence--a prospective study

PurposeA nationwide survey was conducted regarding anticoagulant therapy in patients with acute intracerebral hemorrhage (ICH) on warfarin with nonvalvular atrial fibrillation (NVAF).MethodsA questionnaire on standard therapeutic strategy for warfarin-related ICH in patients with NVAF was mailed to 416 institutes.ResultsA total of 329 physicians (79%) responded with a completed questionnaire. On admission, all respondents stopped warfarin medication and 94% normalized the international normalized ratio (INR) mainly by Vitamin K (63%), followed by fresh frozen plasma (20%), and prothrombin complex concentrate (10%). Afterwards, 91% of the respondents restarted anticoagulation and 3% used antiplatelet for prevention of thromboembolism, but the remaining 6% disagreed with restarting antithrombotic therapy. As contraindications for resuming anticoagulation, recurrent ICH (59%) and poor functional condition (59%) were often chosen. Of those who restarted anticoagulation, the timing was within 4 days in 7%, 5 to 7 days in 21%, 8 to 14 days in 25%, 15 to 28 days in 28% and 29 days or later in 18%. The major key finding on follow-up CT to restart anticoagulation was the absorption tendency of hematomas (47%). When restarting anticoagulation, 76% of the respondents used warfarin alone and 20% used either unfractionated heparin plus warfarin or heparin alone.ConclusionA large majority of respondents responsible for ICH management stopped oral warfarin medication and normalized INR on admission, and restarted anticoagulation after acute ICH in patients with NVAF. However, the strategies to normalize INR and to restart anticoagulant therapy varied greatly and depended on each individual physician's decision.     

丁苯酞对华法林治疗心源性卒中患者抗凝作用的影响

目的 探讨心源性卒中患者使用丁苯酞对华法林抗凝作用的影响。 方法 前瞻性连续纳入成都医学院第一附属医院神经内科2019年6月—2021年12月期间收治的心源性卒中患者,患者入组后随机分为试验组（华法林+丁苯酞）和对照组（华法林）。监测两组患者的国际标准化比值（international standardized ratio,INR）变化情况并收集两组患者的临床资料,比较分析两组患者的INR达标时间、2周内达标率和90 d mRS评分的差异。 结果 本研究共纳入101例心源性卒中患者,试验组51例,对照组50例。两组基线数据（年龄、性别、用药前INR、收缩压和舒张压）差异无统计学意义,入院时试验组的NIHSS评分[10（3.0～15.0）分 vs. 0（0～6.5）分,P<0.001],溶栓率（27.5% vs. 8.0%,P=0.011）与取栓率（25.5% vs. 2.0%,P=0.001）均高于对照组。试验组INR 2周内达标率与对照组相比差异无统计学意义（43.1% vs. 44.0%,P=0.930）。试验组达标时间较对照组明显缩短[（6.50±2.41）d vs.（9.64±4.40）d,P=0.015]。试验组90 d mRS评分与对照组相比,差异无统计学意义[3（0.5～4.0）分 vs. 2（0～3.0）分,P=0.175]。 结论 丁苯酞联合华法林治疗心源性卒中可能缩短华法林的达标时间,需进一步的研究来验证,但对于INR的达标率和90 d mRS评分无影响。     

Transient elevation of the number of microembolic signal in a patient with primary antiphospholipid antibody syndrome]

We report a 55-year-old man complaining of monoparesis of the right arm and dementia. Brain magnetic resonance imaging (MRI) demonstrated multiple foci of fresh cerebral embolism. The serum lupus anticoagulant was positive, however, the serum anticardiolipin antibody and other autoantibodies indicating connective tissue diseases were negative. This patient received a diagnosis of primary antiphospholipid antibody syndrome. Transcranial Doppler(TCD) monitoring of the middle cerebral artery showed the presence of microembolic signal (MES). We initiated anticoagulant therapy with intravenous heparin administration, and three days later we added oral warfarin administration. We used both warfarin and heparin together for only three days. The number of MES increased transiently after initiating of warfarin administration, then decreased by warfarin therapy with production of an international normalized ratio (INR) of prothrombin time over 2. His neurological symptoms normalized except for monoparesis of the right arm. There were no foci of fresh cerebral infarct disclosed on brain MRI performed two months after admission. The treatment strategy for antiphospholipid antibody (APS) patients has not yet been established. Some reports and guideline recommended that the stroke patients with APS should be treated with long-term oral anticoagulant therapy, target INR 2.5 (optimal range 2.0 to 3.0). In this patient, we confirmed a decrease in the number of MES by warfarin therapy with production of INR over 2. In APS patients, detection of MES by TCD is a useful device for adjustment of the warfarin dose. Concerning the course of MES and warfarin therapy, transient elevation of the number of MES after initiation of warfarin therapy would suggest the hypercoagulability due to an acute decrease in serum protein C level. Using the TCD technique, we detected such hypercoagulability for the first time.     

Obesity increases risk of anticoagulation reversal failure with prothrombin complex concentrate in those with intracranial hemorrhage

Background: Not all patients with warfarin-related acute intracranial hemorrhage (ICH) achieve full reversal of international normalized ratio (INR) after the first dose of weight-based prothrombin complex concentrate (PCC). We sought to identify factors associated with anticoagulation reversal failure after the first dose of PCC. Methods: Consecutive patients who were hospitalized with warfarin-related acute ICH at a tertiary center between 1 January 2010 and 31 December 2012 were studied. Anticoagulation reversal failure was defined as INR ≥ 1.5 after the first dose of PCC. Logistic regression was performed to determine the predictors of anticoagulation reversal failure. Results: Fifty-one patients with acute ICH received PCC for warfarin reversal using a weight-based protocol. Overall, 23 (45%) patients did not achieve full reversal of INR after the first dose. Those with anticoagulation reversal failure were obese (body mass index > 30 kg/m²) (41% vs. 14%, p = 0.03), had a higher initial INR (3.0 ± 1.4 vs. 2.0 ± 0.7, p = 0.001), and had a higher prevalence of initial INR >2.0 (22% vs. 67%, p = 0.001), compared with those who were successfully reversed. Multivariable logistic regression identified obesity (odds ratio 7.88, 95% CI 1.12 to 55.68) and initial INR >2.0 (odds ratio 12.49, 95% CI 2.27 to 68.87) as independent predictors of anticoagulation reversal failure. Conclusions: Obesity and elevated initial INR are independently associated with anticoagulation reversal failure using the weight-based PCC protocol in patients with warfarin-related acute ICH. Further studies are needed to determine more effective dosing protocols and individualized strategies for anticoagulation reversal after acute ICH, especially among obese patients.     

Oral anticoagulant-associated intracerebral hemorrhage

The incidence of oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) is growing due to the increasing use of warfarin and the older age of treated patients. Recent population studies reveal that OAC-ICH currently occurs at a frequency comparable to that of subarachnoid hemorrhage. Most frequently, OAC-ICH are located in deep or lobar regions of the brain, although it may also occur in the brainstem. These hemorrhages are larger than spontaneous hematomas and may be fatal in at least 50% of cases. The primary cause of brain injury in patients with OAC-ICH is the direct mechanical disruption of the brain tissue but secondary damage may occur through the intervention of matrix metalloproteinases, glutamate, cytokines, heme, iron, and the chemical toxicity of products such as thrombin, which are released from the clot. The pathogenesis of OAC-ICH also includes the effects of aging, the level of anticoagulation, genetic factors, and a high prevalence of concurrent cerebrovascular conditions, such as cerebral amyloid angiopathy, leukoaraiosis or previous strokes. The treatment of OAC-ICH is challenging and involves rapid reversal of anticoagulation with hemostatic drug therapies such as vitamin K, fresh frozen plasma, prothrombin complex concentrates or recombinant factor VIIa. These therapies may not always be sufficient to stabilize the patient’s clinical condition and lacking randomized controlled trials, the best hematological approach to reverse oral anticoagulation is debated. Other difficult decisions reviewed in this article are whether anticoagulation should be restarted after OAC-ICH, and when anticoagulant treatment should be resumed. The newer oral anticoagulants, which are increasingly being introduced for thromboembolism prevention, may confer a lower risk of intracranial bleeding than warfarin, although they do not have an antidote and their anticoagulant effect is difficult to monitor.     

Anticoagulant treatment in stroke prevention.

This review aims to summarise the value of long-term oral anticoagulant treatment in stroke prevention. Oral anticoagulation is the treatment of first choice in patients with atrial fibrillation (AF) and vascular risk factors and in AF patients with recent cerebral ischemia. The treatment also substantially reduces the risk of stroke in patients after myocardial infarction. The optimal target intensity of anticoagulation in stroke prevention is an International Normalized Ratio (INR) between 2.0 and 3.0. The treatment has been found to be hazardous at INR intensities between 3.0 and 4.5 in patients with transient ischemic attack (TIA) or minor stroke of presumed arterial origin. The value of the treatment in lower intensity in such patients still has to be established.