Antithrombotic treatment and intracerebral haemorrhage: between Scylla and Charybdis

Abstract

In patients who have intracerebral haemorrhage while on antithrombotic treatment, there is no evidence from randomised clinical trials to support decisions with regard to antithrombotic medication. In the acute phase, we advise stopping all antithrombotic treatment with rapid reversal of antithrombotic effects of oral anticoagulants. After the acute phase, we discourage restarting oral anticoagulants in patients with a lobar haematoma caused by cerebral amyloid angiopathy because of the high risk of recurrent bleeding. In these patients, even treatment with platelet inhibitors needs careful weighing of the risks of bleeding and ischaemic stroke. In patients with non-lobar intracerebral haemorrhage, we suggest considering restarting optimal antithrombotic treatment. This includes treatment with oral anticoagulants for patients with atrial fibrillation and/or mechanical valve prosthesis. After intracerebral haemorrhage during oral anticoagulant therapy in patients with atrial fibrillation, direct anticoagulants may be better than vitamin K antagonists, but we await confirmation of this from ongoing trials.

Outcome of intracerebral hemorrhage associated with different oral anticoagulants

“…Furthermore, little is known about the risk of NOAC-ICH or its functional outcome in patients at high risk of ICH, e.g., those with previous ICH or with bleeding-prone arteriopathies. 23 As specific NOAC-ICH reversal agents become available, studies of how these affect clinical and radiologic outcomes are needed. Other treatment options for NOAC-ICH, including hemostatic agents 24 and acute blood pressure management, 25 also need to be investigated, ideally in randomized controlled trials.…”

Re-Initiation of Dabigatran and Direct Factor Xa Antagonists After a Major Bleed

“…For example, superficial (lobar) hemorrhages are often caused by cerebral amyloid angiopathy, a condition that affects cerebral arteries and arterioles and increases the risk of hemorrhage, and is associated with recurrence rates of up to 22%. 24 The incidence of nontraumatic ICH is approximately 25 per 100,000 person-years. 25 It has been estimated that there are approximately 67,000 cases of spontaneous ICH per year in the United States, 26 and anticoagulant-associated ICH accounts for nearly 20% of those.…”

“…In cases of OAC-related ICH, the therapeutic dilemma is that stopping anticoagulation increases the risk of cerebral ischemia, while continuing or restarting treatment after stopping it increases the risk of recurrent bleeding. 24 This has been referred to as “steering between Scylla and Charybdis,” meaning to have to choose between 2 evils. 24 The published reports described below are all retrospective analyses of OAC-related ICH, with varying patient populations (eg, some studies focus on patients with NVAF or patients with mechanical heart valves, while other studies include patients treated for VTE).…”

In patients with intracerebral haemorrhage and concomitant atrial fibrillation, optimal timing of reinitiating anticoagulants may be 7–8 weeks after ICH

“…In patients with intracerebral haemorrhage (ICH) and a concomitant diagnosis of atrial fibrillation (AF), the clinical dilemma arises whether anticoagulant treatment should be (re)started and when 1. In the absence of results from randomised controlled trials, guidelines provide no firm recommendations.…”