This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Background: Intracranial haemorrhage (ICH) is the type of stroke associated with the highest death rate, and about 30% of ICH occurs in patients on antithrombotic treatment. This study relates clinical presentations and outcome of ICH patients on oral anticoagulant (OA) or antiplatelet (AP) therapy admitted to 33 Italian emergency departments (ED). Methods: Consecutive patients were enrolled after cranial computed tomography (CT). Primary outcome was the Modified Rankin Scale (MRS) score at 3 months of follow-up. Common descriptive statistics were computed after stratification for traumatic or spontaneous ICH and identification of the anatomical location of bleeding. Multivariate logistic regression was used to assess predictors of death. Results: We recruited 434 patients on AP therapy and 232 on OA. There were 432 spontaneous and 234 traumatic ICH patients. The proportions of AP and OA patients undergoing neurosurgery were 21.8and 19.4%, respectively, while <30% underwent procoagulant medical treatment. At the 3-month follow-up, the case fatality rate was 42.0%, while disability or death (MRS 3–6) was 68.1%. The odds ratio for death in OA versus AP patients was 2.63 (95% CI 1.73–4.00) in the whole population and 2.80 (95% CI 1.77–4.41) in intraparenchymal event patients. Glasgow Coma Scale, age, spontaneous event and anticoagulant use were found to be predictors of death both in traumatic and spontaneous events. Conclusion: This study confirms the high prevalence of death or disability in OA and AP patients with ICH. As far as the determinants of mortality and disability are concerned, the results of this study might be useful in the clinical management and allocation of resources in the ED setting. The observed low use of procoagulant therapy highlights the need for ED educational programmes to heighten the awareness of available and effective haemostatic treatments.

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The appropriate management of minor head injury (MHI) in patients receiving oral anticoagulant (OAC) is unclear. In this retrospective study, we focused on elderly patients (>65 years) treated with OAC, presented to our emergency department with MHI between 2004 and 2010. Three hundred and six patients with MHI were taking OAC: we documented 7.19% hemorrhages at the first computed tomography (C); 18.19% deaths; 50.1% spontaneous reabsorptions; 22.73% deteriorations of intracranial bleeding without surgical intervention (for clinical comorbidity), and 4.55% neurosurgical interventions. We documented a second positive CT scan in 2 patients (1.51%) who had no symptoms and remained asymptomatic during observation. In both cases, intracranial bleeding resolved spontaneously. The mean international normalized ratio (INR) value was 2.26, higher in the group of patients with bleeding (2.74) than in the group without bleeding (2.19). We found a significant increased risk in patients with posttraumatic loss of consciousness [odds ratio (OR) 28.3], diffuse headache (OR 14.79), vomiting (OR 14.2) and neurological signs (OR 5.27). We did not reach significance in patients with post-traumatic amnesia. Our data confirm the need for a CT scan of any patients on OAC with MHI. None of our patients developed any symptoms or signs during observation, and only 2 patients developed an intracranial hemorrhage in the second CT scan with a favorable evolution. Our data need to be confirmed with an observational study, but we suggest that the second CT could be reserved for patients developing symptoms and signs during observation. We also underline the role of the INR in the stratification of risk.

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