Coagulopathy

Most cerebral hemorrhages occur in patients with arterial disease risk factors (hypertension etc.), but about 10 per cent accompany the use of anticoagulants or other treatments affecting fibrinolysis or thrombosis. If the patient is on heparin when a bleed occurs, it should be reversed with protamine, and if on warfarin with fresh frozen plasma and vitamin K (FeldmaQ 1993). Hemorrhage on warfarin is unusual unless the international normalized ratio (INR) is over 5. If the patient has been on thrombolytics, for example for coronary occlusion, protamine and e-aminocaproic acid may be needed after advice from a hematologist. Such bleeds are usually lobar in distribution. Factor VIII will be needed in a hemophiliac. If the patient is thrombocytopenic or bleeding persists, platelet transfusions may be necessary. Hemorrhage into a tumor is particularly likely in the context of high-grade gliomas, metastases, or melanoma.

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