Re-Anticoagulation after Warfarin-Related Intracerebral Hemorrhage in Patients with Mechanical Heart Valves: The Clinical Dilemma

A 53-year-old woman with a prosthetic heart valve developed a left occipital intracerebral hemorrhage (ICH) while on treatment with warfarin for thromboembolism prophylaxis. The international normalized ratio was 5.8. She presented with left occipital headache, right homonymous hemianopia, and fluent aphasia. The ICH expanded in the initial hours after onset but subsequently stabilized after treatment with vitamin K1, fresh frozen plasma, and recombinant activated factor VII. Her hospital course was stable, and the clinical deficits gradually resolved (aphasia) or improved (right homonymous hemianopia) after hospital discharge. She had the warfarin treatment restarted after 8 days from ICH onset, without subsequent complications. The available data and recommendations on the issue of restarting warfarin anticoagulation after an episode of intracranial bleeding are reviewed.