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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


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