====== Anticoagulant Related Intracerebral Hemorrhage ======

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see also [[Intracranial hemorrhage and anticoagulation]].

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[[Intracerebral hemorrhage]] risk is increased with higher doses than the recommended 100 mg of [[alteplase]] ([[Activase]]®, [[recombinant tissue plasminogen activator]] ([[rt-PA]]))
((Public Health Service. Approval of Thrombolytic Agents. FDA Drug Bull. 1988; 18:6–7))
in older patients, in those with anterior [[MI]] or higher [[Killip class]], and with bolus administration (vs. infusion)
((Mehta SR, Eikelboom JW, Yusuf S. Risk of intracranial hemorrhage with bolus versus infusion thrombolytic therapy: a meta-analysis. Lancet. 2000; 356:449–454)).

When [[heparin]] was used adjunctively, higher doses were associated with a higher risk of [[ICH]]
((Tenecteplase (TNKase) for thrombolysis. Med Letter. 2000; 42:106–108))
ICH is thought to occur in those patients with some preexisting underlying vascular abnormality
((DaSilva VF, Bormanis J. Intracerebral Hemorrhage After Combined Anticoagulant-Thrombolytic Therapy for Myocardial Infarction: Two Case Reports and a Short Review. Neurosurgery. 1992; 30:943–945)).
Immediate coronary angioplasty is safer than [[rt-PA]] when available
((Grines CL, Browne KF, Marco J, et al. A Comparison of Immediate Angioplasty with Thrombolytic Therapy for Acute Myocardial Infarction. N Engl J Med. 1993; 328:673–679)).


===== Epidemiology =====
Affects up to 1% of patients on [[oral anticoagulation]] per year, and is the most feared and devastating complication of this treatment. 

Patients with hemorrhage in a [[lobe]] or [[cerebral amyloid angiopathy]] remain at higher risk for anticoagulant-related [[intracerebral hemorrhage]] (ICH) recurrence than [[thromboembolic event]]s and, therefore would be best managed without [[anticoagulant]]s. 

===== Diagnosis =====


[[Anticoagulant Related Intracerebral Hemorrhage Diagnosis]].

===== Management =====

see [[Anticoagulant Related Intracerebral Hemorrhage Management]].

===== Outcome =====
[[Anticoagulant Related Intracerebral Hemorrhage Outcome]]

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[[Intracerebral hemorrhage]] (ICH) is a life-threatening [[emergency]], the [[incidence]] of which has increased in part due to an increase in the use of [[oral anticoagulant]]s. A [[blood-fluid level]] within the [[hematoma]], as revealed by [[computed tomography]] (CT), has been suggested as a marker for oral [[anticoagulant]]-associated [[ICH]] (OAC-ICH), but the diagnostic [[specificity]] and prognostic value of this finding remain unclear. In 855 patients with CT-confirmed acute ICH scanned within 48 h of symptom onset, Almarzouki et al. investigated the [[sensitivity]] and [[specificity]] of the presence of a CT-defined blood-fluid level (rated blinded to anticoagulant status) for identifying concomitant anticoagulant use. They also investigated the association of the presence of a blood-fluid level with six-month case fatality. Eighteen patients (2.1%) had a blood-fluid level identified on CT; of those with a blood-fluid level, 15 (83.3%) were taking anticoagulants. The specificity of the blood-fluid level for OAC-ICH was 99.4%; the sensitivity was 4.2%. We could not detect an association between the presence of a blood-fluid level and an increased risk of death at six months (OR = 1.21, 95% CI 0.28-3.88, p = 0.769). The presence of a blood-fluid level should alert clinicians to the possibility of OAC-ICH, but the absence of a blood-fluid level is not useful in excluding OAC-ICH
((Almarzouki A, Wilson D, Ambler G, Shakeshaft C, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Brown MM, Muir KW, Jäger HR, Werring DJ. Sensitivity and specificity of blood-fluid levels for oral anticoagulant-associated intracerebral hemorrhage. Sci Rep. 2020 Sep 23;10(1):15529. doi: 10.1038/s41598-020-72504-7. Erratum in: Sci Rep. 2021 Apr 28;11(1):9485. PMID: 32968133; PMCID: PMC7511300.)).