Is unfractionated heparin (UFH) indicated after intracranial bleeding?

Unfractionated Heparin After Intracranial Bleeding

Unfractionated heparin (UFH) is not indicated after intracranial bleeding and should be discontinued when intracranial hemorrhage is present or suspected. 1

Immediate Management After Intracranial Hemorrhage

When intracranial hemorrhage occurs, anticoagulation management requires urgent attention:

• For therapeutic UFH infusion:

  • Immediately discontinue the heparin infusion 1
  • Urgently reverse anticoagulation with IV protamine sulfate 1
  • Dose protamine at 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum single dose: 50 mg) 1
  • If aPTT remains elevated, consider repeat administration of protamine at 0.5 mg per 100 units of UFH 1

• For prophylactic subcutaneous heparin:

  • Routine reversal is not recommended 1
  • Consider reversal only if aPTT is significantly prolonged 1

Timing of Anticoagulation After Intracranial Hemorrhage

The guidelines from the Neurocritical Care Society and Society of Critical Care Medicine provide clear recommendations against using anticoagulation in the acute phase after intracranial hemorrhage 1. This is supported by evidence showing:

1. Urgent anticoagulation with heparin does not improve neurological outcomes or prevent early recurrent stroke in patients with acute ischemic stroke 2

2. Parenteral anticoagulants significantly increase the risk of serious bleeding complications, including symptomatic hemorrhagic transformation 2

3. In the IST study, 1.2% of patients given subcutaneous heparin had a hemorrhagic stroke compared with 0.4% of control participants, and systemic hemorrhage requiring transfusion occurred in 1.3% of heparin-treated patients compared with 0.4% for control participants 2

Special Considerations for DVT Prophylaxis

For DVT prophylaxis after the acute phase of intracranial hemorrhage:

• Low-dose subcutaneous UFH may be considered only for DVT prophylaxis in high-risk patients after hemorrhage stabilization 2
• Evidence suggests that early use (within 48-72 hours) of prophylactic doses may be safe if:
  • Two consecutive CT scans confirm hemorrhage stability 3
  • No confounding coagulopathy exists 3
  • Close neurological monitoring is maintained 3

A study of severe traumatic brain injury patients showed that early prophylactic UFH (within 72 hours) did not increase intracranial bleeding compared to later administration 4. Similarly, a study of low-molecular-weight heparin showed only one patient with symptomatic expansion of intracranial hemorrhage out of 287 patients when prophylaxis was started 48-72 hours post-trauma 3.

Alternatives to UFH

When anticoagulation is eventually required for high-risk conditions after intracranial hemorrhage stabilization:

• Consider low-molecular-weight heparin for DVT prophylaxis, which may have a better safety profile in select patients 3
• For patients with atrial fibrillation requiring anticoagulation, carefully weigh risks and benefits before restarting any anticoagulant 1

Important Caveats

• The presence of intracranial hemorrhage is a strong contraindication to therapeutic anticoagulation in the acute phase
• The decision to restart anticoagulation after intracranial hemorrhage must balance the risk of thromboembolism against the risk of recurrent bleeding
• For patients with mechanical heart valves or other high-risk conditions, the timing of anticoagulation resumption requires careful consideration of individual risk factors
• Brain imaging should always be performed before considering any form of anticoagulation after known or suspected intracranial hemorrhage

In conclusion, while prophylactic doses of UFH may be considered for DVT prevention after hemorrhage stabilization (48-72 hours with stable serial imaging), therapeutic anticoagulation with UFH is not indicated after intracranial hemorrhage in the acute phase.