Anticoagulation in Patients With COVID-19: Benefits and Risks

A CT scan of the brain of a patient with intracranial hemorrhage. The lesion is in the pons in this image
Decisions regarding anticoagulation therapy for patients with COVID-19 should take into account the risk for treatment-associated bleeding, including intracranial hemorrhage.

Decisions regarding anticoagulation therapy for patients with coronavirus disease 2019 (COVID-19) should take into account the associated hypercoagulability state secondary to the acute infection, along with the risk for treatment-associated bleeding, including intracranial hemorrhage (ICH), according to study results published in the Journal of Stroke and Cerebrovascular Diseases.

Recent studies have suggested that patients with COVID-19 are at an increased risk for thrombotic events and anticoagulation is recommended in many cases. However, the risk for bleeding and ICH should be taken into account. As there are limited data on the risk for ICH associated with anticoagulation treatment in patients with COVID-19, the goal of the current study was to examine the benefits and consequences of anticoagulation use in this patient population.

The study cohort included 33 patients with COVID-19 with ICH (mean age, 61.6 years; 21.2% women). Therapeutic dose anticoagulation prior to ICH discovery was administered to 22 (66.7%) patients, while prophylactic dose was administered to 3 (9.1%) patients. Of the remainder, 2 patients (6.1%) had been on long-term warfarin and dabigatran prior to admission and 6 patients (18.2%) had never received anticoagulation before or during the hospitalization.

The most common reasons for therapeutic dose of anticoagulation included elevated D-dimer levels (81.8% of cases) and a known or suspected thrombus (18.2% of cases). Most patients received intravenous unfractionated heparin only (68.2%). Of these 22 patients on therapeutic anticoagulation, 12 (54.5%) had a supratherapeutic anti-factor Xa or partial thromboplastin time within 72 hours prior to the ICH.

Parenchymal hemorrhages with mass effect and herniation occurred in 5 (15.2%) patients, with a 100% mortality rate. Of the remaining 28 patients with ICH, 7 (25%) had punctate hemorrhages, 17 (60.7%) had small- sized hemorrhages, and 4 (14.3%) had a large single site of hemorrhage without evidence of herniation.

The study had several limitations, according to the researchers, including the descriptive nature, small sample size, inability to complete MRI in all patients or to review all patients receiving anticoagulation to assess how many of them had ICH.

“[W]e believe our study provides important initial data regarding ICH and anticoagulation in patients hospitalized with COVID-19,” concluded the researchers.


Dogra S, Jain R, Cao M, et al. Hemorrhagic stroke and anticoagulation in COVID-19 [published online May 23, 2020). J Stroke Cerebrovasc Dis. doi:10.1016/j.jstrokecerebrovasdis.2020.104984