PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of jrsocmedLink to Publisher's site
 
J R Soc Med. 2004 June; 97(6): 308–309.
PMCID: PMC1079508

Dilemmas in managing intracerebral haemorrhage and thromboembolism

Dr Shah and Dr Dawson's dilemma (March 2004 JRSM1) of managing intracerebral haemorrhage (ICH) in a patient previously anticoagulated for a prosthetic heart valve will be familiar to many clinicians. Whilst re-anticoagulation would be current practice, this is based on perceptions that the benefits of thromboembolism prevention surpass the risks of re-haemorrhage.2 Such decisions are prone to recall or availability bias, given the varying risks of valve thromboembolism and the fragmentary evidence base on risks of rebleeding with further antithrombotics/anticoagulants.

Clinical trials are unlikely to resolve this dilemma, not least because of the difficulty of recruiting sufficient participants. Decision analysis presents an alternative solution—developing a framework in which to combine variations in multiple probabilities within a mathematical model. Such techniques allow examination of current practices where no consensus exists, using a range of values/scenarios to test the feasibility of the model. These techniques have already seen successful use in re-examining evidence-based guidelines and in assessing decision-making in atrial fibrillation and intracerebral haemorrhage.3,4

We are currently constructing a decision model to explore the dilemma faced by Shah and Dawson, testing the effects of using anticoagulants and antiplatelet agents in patients with mechanical valves and ICH. A key test of decision modelling outcomes is to review them against current practices, and it is noteworthy that recent case reports have highlighted the potential short-term use of antiplatelet agents such as aspirin and clopidogrel in place of immediate anticoagulation following cerebral bleeding.5

References

1. Shah N, Dawson SL. Intracerebral haemorrhage, prosthetic heart valve and anticoagulation. J R Soc Med. 2004;97: 129-30 [PMC free article] [PubMed]
2. Crawley F, Bevan D, Wren D. Management of intracranial bleeding associated with anticoagulation: balancing the risk of further bleeding against thromboembolism from prosthetic heart valves. J Neurol Neurosurg Psychiatry 2000;69: 396-8 [PMC free article] [PubMed]
3. Sarasin FP. Decision analysis and the implementation of evidence-based medicine. Quart J Med 1999;92: 669-71 [PubMed]
4. Eckman MH, Rosand J, Knudsen KA, Singer DE, Greenberg SM et al. Can patients be anticoagulated after intracerebral haemorrhage? A decision analysis. Stroke 2003;34: 1710-16 [PubMed]
5. Timperley J, Clarke NRA, Banning AP. New antiplatelet agents and prosthetic heart valves. Quart J Med 2002;95: 706-7 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press