Should you take heparin (anticoagulant) for an intracerebral hemorrhage?

Heparin Should Not Be Used in Patients with Intracerebral Hemorrhage

Heparin should be discontinued immediately in patients with intracerebral hemorrhage (ICH) and the anticoagulant effect should be reversed with appropriate agents. 1

Rationale for Avoiding Heparin in ICH

Intracerebral hemorrhage represents an active bleeding state where anticoagulation is absolutely contraindicated. The FDA labeling for heparin specifically lists "an uncontrolled active bleeding state" as a contraindication for heparin use 2. Guidelines are clear on this point:

• The Neurocritical Care Society and Society of Critical Care Medicine recommend urgently reversing anticoagulation when ICH develops during full-dose heparin infusion 1
• The American Heart Association/American Stroke Association guidelines state that all anticoagulants should be discontinued during the acute period for at least 1-2 weeks after hemorrhage 1

Management Algorithm for Patients with ICH on Anticoagulation

1. Immediate discontinuation of all anticoagulants including heparin 1

2. Reversal of anticoagulation effect:

   • For unfractionated heparin: Administer IV protamine sulfate at 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum single dose 50 mg) 1
   • For LMWH: Administer protamine according to specific LMWH type and timing 1

3. Duration of anticoagulant discontinuation:

   • Maintain off anticoagulation for at least 1-2 weeks after the hemorrhage 1

Considerations for Future Anticoagulation

If anticoagulation is absolutely necessary in the future (e.g., high-risk mechanical heart valve):

• Consider delaying reinstitution for 3-4 weeks after ICH 1
• IV heparin may be safer than oral anticoagulation when restarting 1
• Maintain INRs in the lower end of the therapeutic range if warfarin is used 1

Special Considerations

The location of the ICH affects the risk-benefit analysis for future anticoagulation:

• Patients with lobar ICHs or evidence of cerebral amyloid angiopathy have higher risk of recurrent ICH if anticoagulation is resumed 1, 3
• A decision analysis study found that survivors of lobar ICH with atrial fibrillation should not receive long-term anticoagulation, while those with deep hemispheric ICH might benefit only if they have particularly high thromboembolic risk 3

Venous Thromboembolism (VTE) Prophylaxis

While therapeutic anticoagulation is contraindicated, VTE prophylaxis presents a more nuanced decision:

• Non-pharmacologic methods (compression devices) should be used initially 1
• Low-dose LMWH or unfractionated heparin for VTE prophylaxis may be considered after 48-72 hours of stability, but evidence is limited 4, 5
• A meta-analysis showed prophylactic heparin was associated with a non-significant increase in hematoma enlargement and mortality 5

Important Caveats

1. Hemorrhagic transformation of ischemic stroke is different from primary ICH and may be managed differently - anticoagulation may sometimes be continued depending on the specific clinical scenario 1

2. Timing matters - the risk of hematoma expansion is highest in the first 24-48 hours after ICH, making this period particularly high-risk for any anticoagulation 6

3. Risk-benefit assessment - while some studies suggest prophylactic doses of heparin may be safe after 48 hours of stability 6, the INTERACT2 study showed heparin use was associated with poorer outcomes, particularly increased disability 7

In conclusion, therapeutic heparin should never be used in the setting of acute intracerebral hemorrhage, and even prophylactic doses should be avoided in the first 48 hours. Non-pharmacologic VTE prophylaxis should be the initial approach.