Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-78c5997874-mlc7c Total loading time: 0 Render date: 2024-11-16T16:10:26.012Z Has data issue: false hasContentIssue false

Chapter 19 - Iatrogenic intracerebral hemorrhage due to oral anticoagulation therapy: risk factors and diagnosis

from Section VI - Iatrogenic hemorrhagic strokes: anticoagulation-related intracranial hemorrhage

Published online by Cambridge University Press:  20 October 2016

By
Alexander Tsiskaridze
Edited by
Alexander Tsiskaridze ,
Arne Lindgren  and
Adnan I. Qureshi
Alexander Tsiskaridze
Affiliation:
Sarajishvili Institute of Neurology, Tblisi State University, Georgia
Arne Lindgren
Affiliation:
Department of Neurology, University Hospital Lund, Sweden
Adnan I. Qureshi
Affiliation:
Department of Neurology, University of Minnesota
Get access

Summary

A summary is not available for this content so a preview has been provided. Please use the Get access link above for information on how to access this content.
Image of the first page of this content. For PDF version, please use the ‘Save PDF’ preceeding this image.'
Type
Chapter
Information
Treatment-Related Stroke
Including Iatrogenic and In-Hospital Strokes
 , pp. 189 - 202
Publisher: Cambridge University Press
Print publication year: 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ogilvie, I M, Newton, N, Welner, S A, Cowell, W, Lip, G Y H. Underuse of oral anticoagulants in atrial fibrillation: A systematic review. Am J Med. 2010; 123:638–45.Google Scholar
Shroff, G R, Solid, C A, Herzog, C A. Temporal trends in ischemic stroke and anticoagulation therapy among Medicare patients with atrial fibrillation: A 15-year perspective (1992–2007). JAMA Intern Med. 2013; 173:159–60.CrossRefGoogle ScholarPubMed
Connolly, S J, Ezekowitz, M D, Yusuf, S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009; 361:1139–51.Google Scholar
Patel, M R, Mahaffey, K W, Garg, J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011; 365:883–91.Google Scholar
Granger, C B, Alexander, J H, McMurray, J J V, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365:981–92.Google Scholar
Connolly, S J, Eikelboom, J, Joyner, C, et al. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011; 364:806–17.CrossRefGoogle ScholarPubMed
Giugliano, R P, Ruff, C T, Rost, N S, et al. Cerebrovascular events in 21 105 patients with atrial fibrillation randomized to edoxaban versus warfarin: Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48. Stroke. 2014; 45:2372–8.Google Scholar
Connolly, S J, Wallentin, L, Ezekowitz, M D, et al. The long-term multicenter observational study of dabigatran treatment in patients with atrial fibrillation (RELY-ABLE) study. Circulation. 2013; 128:237–43.Google Scholar
Hart, R G, Diener, H C, Yang, S, et al. Intracranial hemorrhage in atrial fibrillation patients during anticoagulation with warfarin or dabigatran: The RE-LY trial. Stroke. 2012; 43:1511–17.Google Scholar
Hankey, G J, Stevens, S R, Piccini, J P, et al. Intracranial hemorrhage among patients with atrial fibrillation anticoagulated with warfarin or rivaroxaban: The rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation. Stroke. 2014; 45:1304–12.Google Scholar
Ruff, C T, Giugliano, R P, Braunwald, E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014; 383:955–62.Google Scholar
Gage, B F, Yan, Y, Milligan, P E, Waterman, A D, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006; 151:713–19.Google Scholar
Pisters, R, Lane, D A, Nieuwlaat, R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest. 2010; 138:1093–100.Google Scholar
Fang, M C, Go, A S, Chang, Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study. J Am Coll Cardiol. 2011; 58:395–401.Google Scholar
Apostolakis, S, Lane, D A, Guo, Y, Buller, H, Lip, G Y. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: The AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol. 2012; 60:861–7.Google Scholar
Hart, R G, Boop, B S, Anderson, D C. Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke. 1995; 26:1471–7.Google Scholar
Fang, M C, Go, A S, Chang, Y, Hylek, E M, et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007; 120:700–5.Google Scholar
Steiner, T, Kaste, M, Forsting, M, et al. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Recommendations for the management of intracranial haemorrhage – part I: Spontaneous intracerebral haemorrhage. Cerebrovasc Dis. 2006; 22:294–316.Google Scholar
Själander, A, Engström, G, Berntorp, E, Svensson, P. Risk of haemorrhagic stroke in patients with oral anticoagulation compared with the general population. J Intern Med. 2003; 254:434–8.Google Scholar
Go, A S, Hylek, E M, Phillips, K A, Chang, Y, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: the AnTicoagulation and Risk factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285:2370–5.Google Scholar
Franke, C L, de Jonge, J, van Swieten, J C, Op de Coul, A A, van Gijn, J. Intracerebral hematomas during anticoagulant treatment. Stroke. 1990; 21:726–30.Google Scholar
Flibotte, J J, Hagan, N, O’Donnell, J, Greenberg, S M, Rosand, J. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology. 2004; 63:1059–64.Google Scholar
Sacco, S, Marini, C, Toni, D, Olivieri, L, Carolei, A. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke. 2009; 40:394–9.Google Scholar
Horstmann, S, Rizos, T, Lauseker, M, et al. Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study. J Neurol. 2013; 260:2046–51.Google Scholar
Lip, G Y, Andreotti, F, Fauchier, L, et al. Bleeding risk assessment and management in atrial fibrillation patients: A position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace. 2011; 13:723–46.Google Scholar
Petitti, D, Strom, B, Melmon, K. Duration of warfarin anticoagulation therapy and the probabilities or recurrent thromboembolism and hemorrhage. Am J Med. 1986; 81:255–9.Google Scholar
Fihn, S D, McDonnel, M, Martin, D, et al. Warfarin Optimized Outpatient Follow-up Study Group. Risk factors for complications of chronic anticoagulation: A multicenter study. Ann Intern Med. 1993; 118:511–20.Google Scholar
Palareti, G, Leali, N, Coccheri, S, et al. Bleeding complications of oral anticoagulant treatment: An inception-cohort, prospective collaborative study (ISCOAT). Lancet. 1996; 348:423–8.Google Scholar
Landefeld, C S, Goldman, L. Major bleeding in outpatients treated with warfarin: Incidence and prediction by factors known at the start of outpatient therapy. Am J Med. 1989; 87:144–52.Google Scholar
Hart, R G, Tonarelli, S B, Pearce, L A. Avoiding central nervous system bleeding during antithrombotic therapy: Recent data and ideas. Stroke. 2005; 36:1588–93.Google Scholar
Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994; 154:1449–57.Google Scholar
SPAF-Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke prevention in atrial fibrillation II study. Lancet. 1994; 343:687–91.Google Scholar
Olsson, S B. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): Randomised controlled trial. Lancet. 2003; 362:1691–8.Google Scholar
Albers, G W, Diener, H C, Frison, L, et al. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA. 2005; 293:690–8.Google Scholar
Di Marco, J P, Flaker, G, Waldo, A L, et al. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: Observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J. 2005; 149:650–6.Google Scholar
Landefeld, C S, Goldman, L. Major bleeding in outpatients treated with warfarin: Incidence and prediction by factors known at the start of outpatient therapy. Am J Med. 1989; 87:144–52.Google Scholar
van der Meer, F J, Rosendaal, F R, Vandenbroucke, J P, Briet, E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med. 1993; 153:1557–62.Google Scholar
Steffensen, F H, Kristensen, K, Ejlersen, E, Dahlerup, J F, Sorensen, H T. Major haemorrhagic complications during oral anticoagulant therapy in a Danish population-based cohort. J Intern Med. 1997; 242:497–503.Google Scholar
Beyth, R J, Quinn, L M, Landefeld, C S. Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. Am J Med. 1998; 105:91–9.Google Scholar
Go, A S, Hylek, E M, Chang, Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: How well do randomized trials translate into clinical practice? JAMA. 2003; 290:2685–92.Google Scholar
Hylek, E M, Evans-Molina, C, Shea, C, Henault, L E, Regan, S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007; 115:2689–96.Google Scholar
Poli, D, Antonucci, E, Grifoni, E, et al. Bleeding risk during oral anticoagulation in atrial fibrillation patients older than 80 years. J Am Coll Cardiol. 2009; 54:999–1002.Google Scholar
Vandenbroucke, J P. Why do the results of randomised and observational studies differ? BMJ. 2011; 343:d7020.Google Scholar
Charidimou, A, Shakeshaft, C, Werring, D J. Cerebral microbleeds on magnetic resonance imaging and anticoagulant-associated intracerebral hemorrhage risk. Front Neurol. 2012; 19:133.Google Scholar
Larsen, T B, Rasmussen, L H, Skjøth, F, Due, K M, et al. Efficacy and safety of dabigatran etexilate and warfarin in “real-world” patients with atrial fibrillation: A prospective nationwide cohort study. J Am Coll Cardiol. 2013; 61:2264–73.CrossRefGoogle ScholarPubMed
Southworth, M R, Reichman, M E, Unger, E F. Dabigatran and postmarketing reports of bleeding. N Engl J Med. 2013; 368:1272–4.Google Scholar
Hankey, G J. Intracranial hemorrhage and novel anticoagulants for atrial fibrillation: What have we learned? Curr Cardiol Rep. 2014; 16:480.Google Scholar
Wintzen, A R, De Jonge, H, Loeliger, E A, Botts, G T A M. The risk of intracerebral hemorrhage during oral anticoagulant treatment: A population study. Ann Neurol. 1984; 16:533–8.Google Scholar
Fisher, C M. Pathological observations in hypertensive cerebral hemorrhage. J Neuropathol Exp Neurol. 1971; 30:536–50.Google Scholar
Brouwers, H B, Goldstein, J N, Romero, J M, Rosand, J. Clinical applications of the computed tomography angiography spot sign in acute intracerebral hemorrhage: A review. Stroke. 2012; 43:3427–32.Google Scholar
Demchuk, A M, Dowlatshahi, D, Rodriguez-Luna, D, et al. PREDICT/Sunnybrook ICH CTA study group. Prediction of hematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): A prospective observational study. Lancet Neurol. 2012; 11:307–14.Google Scholar
Delgado Almandoz, J E, Yoo, A J, Stone, M J, et al. Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: The spot sign score. Stroke. 2009; 40:2994–3000.Google Scholar
Brouwers, H B, Biffi, A, McNamara, K A, et al. Apolipoprotein E genotype is associated with CT angiography spot sign in lobar intracerebral hemorrhage. Stroke. 2012; 43:2120–5.Google Scholar
Brouwers, H B, Greenberg, S M. Hematoma expansion following acute intracerebral hemorrhage. Cerebrovasc Dis. 2013; 35:195–201.Google Scholar
Greenberg, C H, Frosch, M P, Goldstein, J N, Rosand, J, Greenberg, S M. Modeling intracerebral hemorrhage growth and response to anticoagulation. PLoS One. 2012; 7:e48458.Google Scholar
Grysiewicz, R, Gorelick, P B. Incidence, mortality, and risk factors for oral anticoagulant-associated intracranial hemorrhage in patients with atrial fibrillation. J Stroke Cerebrovasc Dis. 2014; 23:2479–88.CrossRefGoogle ScholarPubMed
Hylek, E M, Singer, D E. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med. 1994; 120:897–902.Google Scholar
Fang, M C, Chang, Y, Hylek, E M, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004; 16:745–52.Google Scholar
Stroke Prevention in Atrial Fibrillation (SPAF) II Study. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation. Lancet. 1994; 343:687–91.Google Scholar
Birman-Deych, E, Radford, M J, Nilasena, D S, Gage, B F. Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. Stroke. 2006; 37:1070–4.Google Scholar
Shen, A Y, Yao, J F, Brar, S S, Jorgensen, M B, Chen, W. Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation. J Am Coll Cardiol. 2007; 50:309–15.Google Scholar
Hylek, E M, Go, A S, Chang, Y, Jensvold, N G, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med. 2003; 349:1019–26.Google Scholar
Berwaerts, J, Webster, J. Analysis of risk factors involved in oral-anticoagulant-related intracranial haemorrhages. QJM. 2000; 93:513–21.Google Scholar
Fric-Shamji, E C, Shamji, M F, Cole, J, Benoit, B G. Modifiable risk factors for intracerebral hemorrhage: study of anticoagulated patients. Can Fam Physician. 2008; 54:1138–9.Google Scholar
The Stroke Prevention In Reversible Ischemia Trial (SPIRIT) Study Group. A randomized trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin. Ann Neurol. 1997; 42:857–65.Google Scholar
Revesz, T, Holton, J L, Lashley, T, et al. Sporadic and familial cerebral amyloid angiopathies. Brain Pathol. 2002; 12:343–57.Google Scholar
Greenberg, S M, Rebeck, G W, Vonsattel, J P, Gomez-Isla, T, Hyman, B T. Apolipo-protein E epsilon 4 and cerebral hemorrhage associated with amyloid angiopathy. Ann Neurol. 1995; 38:254–9.Google Scholar
Nicoll, J A, Burnett, C, Love, S, et al. High frequency of apolipoprotein E epsilon 2 allele in hemorrhage due to cerebral amyloid angiopathy. Ann Neurol. 1997; 41:716–21.Google Scholar
Biffi, A, Sonni, A, Anderson, C D, et al. Variants at APOE influence risk of deep and lobar intracerebral hemorrhage. Ann Neurol. 2010; 68:934–43.Google Scholar
Rosand, J, Hylek, E M, O’Donnell, H C, Greenberg, S M. Warfarin-associated hemorrhage and cerebral amyloid angiopathy: A genetic and pathologic study. Neurology. 2000; 55:947.Google Scholar
Melo, T P, Bogousslavsky, J, Regli, F, Janzer, R. Fatal hemorrhage during anticoagulation of cardioembolic infarction: Role of cerebral amyloid angiopathy. Eur Neurol. 1993: 33:9–12.Google Scholar
Flockhart, D A, O’Kane, D, Williams, M S, et al. Pharmacogenetic testing of CYP2C9 and VKORC1 alleles for warfarin. Genet Med. 2008; 10:139–50.Google Scholar
Stehle, S, Kirchheiner, J, Lazar, A, Fuhr, U. Pharmacogenetics of oral anticoagulants: A basis for dose individualization. Clin Pharmacokinet. 2008; 47:565–94.Google Scholar
Higashi, M K, Veenstra, D L, Kondo, L M, et al. Association between CYP2C9 genetic variants and anticoagulation-related outcomes during warfarin therapy. JAMA. 2002; 287:1690–8.Google Scholar
Rybak, I, Ehle, M, Buckley, L, Fanikos, J. Efficacy and safety of novel anticoagulants compared with established agents. Ther Adv Hematol. 2011; 2:175–95.Google Scholar
Mega, J L, Walker, J R, Ruff, C T, et al. Genetics and the clinical response to warfarin and edoxaban: Findings from the randomised, double-blind ENGAGE AF-TIMI 48 trial. Lancet. 2015; 385:2280–7.Google Scholar
Shireman, T I, Howard, P A, Kresowik, T F, Ellerbeck, E F. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke. 2004; 35:2362–7.Google Scholar
Gouw, A A, Seewann, A, Van Der Flier, W M, et al. Heterogeneity of small vessel disease: A systematic review of MRI and histopathology correlations. J Neurol Neurosurg Psychiatr. 2010; 82:126–35.Google Scholar
Schmidt, R, Grazer, A, Enzinger, C, et al. MRI-detected white matter lesions: Do they really matter? J Neural Transm. 2011; 118:673–81.Google Scholar
Gorter, J W. Major bleeding during anticoagulation after cerebral ischemia: Patterns and risk factors. Stroke Prevention In Reversible Ischemia Trial (SPIRIT). European Atrial Fibrillation Trial (EAFT) study groups. Neurology. 1999; 53:1319–27.Google Scholar
Smith, E E, Rosand, J, Knudsen, K A, Hylek, E M, Greenberg, S M. Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke. Neurology. 2002; 59:193–7.Google Scholar
Greenberg, S M, Vernooij, M W, Cordonnier, C, et al. Cerebral microbleeds: A guide to detection and interpretation. Lancet Neurol. 2009; 8:165–74.Google Scholar
Lee, S H, Ryu, W S, Roh, J K. Cerebral microbleeds are a risk factor for warfarin-related intracerebral hemorrhage. Neurology. 2009; 72:171–6.Google Scholar
Ueno, H, Naka, H, Ohshita, T, et al. Association between cerebral microbleeds on T2*-weighted MR images and recurrent hemorrhagic stroke in patients treated with warfarin following ischemic stroke. Am J Neuroradiol. 2008; 29:1483–6.Google Scholar
Lovelock, C E, Cordonnier, C, Naka, H, et al. Edinburgh Stroke Study Group. Antithrombotic drug use, cerebral microbleeds, and intracerebral hemorrhage: a systematic review of published and unpublished studies. Stroke. 2010; 41:1222–8.Google Scholar
Charidimou, A, Peeters, A P, Jäger, R, et al. Cortical superficial siderosis and intracerebral hemorrhage risk in cerebral amyloid angiopathy. Neurology. 2013; 81:1666–73.Google Scholar
Kidwell, C S, Chalela, J A, Saver, J L, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004; 292:1823–30.Google Scholar
Greenberg, S M, Eng, J A, Ning, M, Smith, E E, Rosand, J. Hemorrhage burden predicts recurrent intracerebral hemorrhage after lobar hemorrhage. Stroke. 2004; 35:1415–20.Google Scholar
Cucchiara, B, Messe, S, Sansing, L, Kasner, S, Lyden, P; CHANT Investigators. Hematoma growth in oral anticoagulant related intracerebral hemorrhage. Stroke. 2008; 39:2993–6.Google Scholar
Flaherty, M L, Tao, H, Haverbusch, M, et al. Warfarin use leads to larger intracerebral hematomas. Neurology. 2008; 71:1084–9.Google Scholar
Sheth, K N, Cushing, T A, Wendell, L, et al. Comparison of hematoma shape and volume estimates in warfarin versus non-warfarin-related intracerebral hemorrhage. Neurocrit Care. 2010; 12:30–4.Google Scholar
Levine, J M, Snider, R, Finkelstein, D, et al. Early edema in warfarin-related intracerebral hemorrhage. Neurocrit Care. 2007; 7:58–63.Google Scholar
Biffi, A, Battey, T W, Ayres, A M, et al. Warfarin-related intraventricular hemorrhage: imaging and outcome. Neurology. 2011; 15:1840–6.Google Scholar
Kase, C S, Robinson, R K, Stein, R W, et al. Anticoagulant-related intracerebral hemorrhage. Neurology. 1985; 35:943–8.Google Scholar
Toyoda, K, Okada, Y, Ibayashi, S, et al. Antithrombotic therapy and predilection for cerebellar hemorrhage. Cerebrovasc Dis. 2007; 23:109.Google Scholar
Brott, T, Broderick, J, Kothari, R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997; 28:1–5.Google Scholar
Balami, J S, Buchan, A M. Complications of intracerebral haemorrhage. Lancet Neurol. 2012; 11:101–18.Google Scholar
Veltkamp, R, Rizos, T, Horstmann, S. Intracerebral bleeding in patients on antithrombotic agents. Semin Thromb Hemost. 2013; 39:963–71.Google Scholar
Sjöblom, L, Hårdemark, H G, Lindgren, A, et al. Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: A Swedish multicenter study. Stroke. 2001; 32:2567–74.Google Scholar
Rosand, J, Eckman, M H, Knudsen, K A, Singer, D E, Greenberg, S M. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004; 164:880–4.Google Scholar
Zubkov, A Y, Mandrekar, J N, Claassen, D O, et al. Predictors of outcome in warfarin-related intracerebral hemorrhage. Arch Neurol. 2008; 65:1320–5.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×