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December 2000

The Dilemma of Reinstituting Anticoagulation for Patients With Cardioembolic Sources and Intracranial Hemorrhage: How Wide Is the Strait Between Skylla and Karybdis?

Arch Neurol. 2000;57(12):1682-1684. doi:10.1001/archneur.57.12.1682

And it happened that Ulysses after successfully fighting the sirens' sweet seductive songs entered the strait between Skylla, a deadly current, and Karybdis, a terrifying creature living on a mist-clouded rock just opposite of Skylla, both being a deadly threat to the ancient mariners.—Homer, Tales of the Brave Ulysses

In this issue of the ARCHIVES, Phan and colleagues1 report an extension (hereinafter referred to as "the Mayo series") of a previously published series2 on patients with strict indication for oral anticoagulants who had intracranial bleeding. With a 1% to 2% estimated yearly bleeding risk among anticoagulated patients this is a condition that may not infrequently be found in neurointensive care units. Unfortunately, very little prospective data are available concerning the medical management of these cases in the first days after bleeding. The incidence of embolism in the first months after halting anticoagulation therapy is not precisely known, but varies considerably depending on the underlying cardiac condition. In high-risk patients with atrial fibrillation, the 1-year rate of brain embolism may be 12% or more. For those treated with some modern artificial valves, the embolism risk without anticoagulation is in the range of 4 per 100 patient-years,3,4 but may vary widely with the type of valve used and concomitant cardiac conditions.

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