When is full-dose IV heparin indicated in the treatment of stroke or transient ischemic attack (TIA)?

Updated: Dec 18, 2018
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Some of the indications currently proposed by many experts for early full-dose IV heparin after stroke or transient ischemic attack (TIA) include the following:

  • Conditions with potential high risk of early cardiogenic reembolization, such as atrial fibrillation with proven intracardial thrombus on echocardiography, artificial valves, left atrial or ventricular thrombi, or myocardial infarction during the last 4 weeks

  • Symptomatic dissection of the arteries supplying the brain (after exclusion of subarachnoid hemorrhage on CT scan)

  • Symptomatic extracranial or intracranial arteriosclerotic stenosis with crescendo TIAs or early progressive stroke

  • Basilar artery occlusion before or after intra-arterial pharmacological or mechanical thrombolysis.

  • Known hypercoagulable states (eg, protein C and S deficiencies, activated protein C [APC] resistance, antithrombin deficiency, relevant titer of antiphospholipid antibodies)

  • Cerebral venous sinus thrombosis

The use of anticoagulation in cerebral venous sinus thrombosis is based on open case series with no controls. Anticoagulation has been used even in the presence of hemorrhagic infarctions typical of this condition. Authors have reported good outcomes compared with historical controls.

Conclusive data are lacking about the management of anticoagulation in patients with hemorrhagic conversion of ischemic brain infarction or primary cerebral hemorrhage who have an absolute indication for anticoagulation for the prevention of embolism (ie, atrial fibrillation or mechanical heart valves). Small retrospective case series of patients with urgent need for anticoagulation (eg, with artificial heart valves) showed a better outcome for those treated with full-dose IV heparin (only after normalization of INR values by administration of prothrombin complex and/or other warfarin antagonists) than for those treated with low-dose subcutaneous heparin; however, these studies lack concomitant control subjects, thus making any conclusions about true efficacy and safety difficult.

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