Neuroscience · Year 2 · from Neuroscience
Case 3: Intracerebral Hemorrhage on Anticoagulation
Patient Presentation
Demographics: 76-year-old male
Chief Complaint: Sudden severe headache and left-sided weakness
History of Present Illness: The patient was reading when he suddenly developed a severe headache and noticed his left arm felt weak. His wife noted he seemed confused and had difficulty speaking. He has atrial fibrillation and has been taking warfarin for 5 years. He also has a history of hypertension and chronic kidney disease.
Physical Examination:
- Vital signs: BP 198/108, HR 88 irregular, T 37.2C
- General: Drowsy, oriented to person only
- Neurological:
- Mental status: Lethargic; follows simple commands inconsistently
- Cranial nerves: Eyes deviated to the right; left homonymous hemianopia; left facial droop
- Motor: Left arm 1/5, left leg 2/5, right side 5/5
- Sensory: Does not respond to pinprick on left
- NIHSS: 18
Imaging:
- CT head without contrast: 45 mL hyperdense (bright white) hemorrhage in right basal ganglia with mass effect, 6 mm midline shift to left; surrounding hypodense edema; intraventricular extension into right lateral ventricle
Laboratory:
- INR: 3.2 (supratherapeutic on warfarin)
- Creatinine: 1.8 mg/dL
- Hemoglobin: 12.8 g/dL
- Platelet count: 178,000
Diagnosis: Spontaneous intracerebral hemorrhage (hypertensive) in setting of supratherapeutic anticoagulation
Treatment:
Immediate Reversal of Anticoagulation:
- Four-factor prothrombin complex concentrate (4F-PCC) 25 units/kg IV
- Vitamin K 10 mg IV
- Repeat INR at 30 minutes: 1.3 (reversed)
Blood Pressure Management:
- Target systolic <140 mmHg per INTERACT2 protocol
- Nicardipine infusion to achieve target
Neurocritical Care:
- ICU admission
- Frequent neurological checks
- Head of bed elevated 30 degrees
- Seizure prophylaxis (levetiracetam)
- DVT prophylaxis with sequential compression devices (no heparin initially)
- Neurosurgery consultation (surgical evacuation not indicated for deep hemorrhage without deterioration)
Repeat Imaging:
- CT at 6 hours: Stable hemorrhage volume; no expansion
Clinical Course: The patient remained stable without hematoma expansion. Over 1 week, his mental status gradually improved. At discharge to rehabilitation on day 10, he was following commands reliably with persistent left hemiparesis (arm 2/5, leg 3/5). Anticoagulation was not restarted; cardiology was consulted for left atrial appendage closure consideration as alternative stroke prevention strategy.
3-Month Outcome: Modified Rankin Scale 3 (moderate disability, requiring some help with daily activities). Left hemiparesis improved to 3+/5 arm, 4/5 leg.
Clinical Pearl: Intracerebral hemorrhage in anticoagulated patients requires immediate reversal to prevent hematoma expansion (which occurs in ~30% within the first few hours and predicts worse outcome). 4F-PCC rapidly reverses warfarin effect. Blood pressure should be lowered aggressively (target <140 systolic) to reduce expansion risk. Unlike ischemic stroke where "time is brain" drives reperfusion therapy, ICH management focuses on preventing secondary injury through reversal, blood pressure control, and avoiding complications. The decision about long-term anticoagulation involves balancing stroke prevention (high risk in atrial fibrillation) against recurrent hemorrhage risk.
Clinical Image
Image Description: Diffusion-weighted MRI (DWI) demonstrating acute ischemic stroke as a region of restricted diffusion (bright signal) in the middle cerebral artery territory. DWI is highly sensitive for acute ischemia, showing changes within minutes of stroke onset, making it the gold standard for confirming acute infarction.
Attribution: Image from Radiopaedia (https://radiopaedia.org/), Creative Commons Attribution-NonCommercial-ShareAlike 3.0 license.