Management of oral anticoagulation after intracerebral hemorrhage

Abstract

Background: The most recent years have significantly expanded knowledge regarding risks and benefits of resuming oral anticoagulation (OAC) after intracerebral hemorrhage (ICH). No randomized data is yet available, though several large observational studies and meta-analyses have investigated the impact of resuming OAC on thromboembolic versus hemorrhagic complications in these high-risk patients after ICH. Aims: The present review will summarize the most important studies conducted over the last years and will focus on relevant factors help guiding on decision-making on whether to start OAC after ICH. Summary of review: Several important factors (demographic, co-morbidities, clinical characteristics) need to be considered before individual decision-making for or against OAC is employed. Existing observational data suggest that patients after ICH with indication for long-term oral anticoagulation benefit from OAC given significant reductions of thromboembolic events without significantly increasing bleeding complications. Studies even suggest that thereby also clinical outcomes may be improved. Prospective trials currently recruiting patients will clarify whether OAC after ICHor left atrial appendage closure as a meaningful alternative-is of clinical net-benefit. Conclusions: Large sized and well-executed investigations (moderate quality of evidence) are showing that OAC resumption after ICH decreases thromboembolic complications and long-term mortality without significantly increasing bleeding complications. Further, data suggest that resumption may be safer in non-lobar ICH compared to lobar ICH, but overall, thoughtful selection, strict blood pressure control, and precise communication are paramount before starting a patient on OAC after ICH.

Role of rehabilitation in prevention of early thromboembolic complications in hemorrhagic stroke

“…Contrarily, recurrence rate of ICH during anticoagulant treatment is higher: 2,6 to 8.7% anualy (13). Rebleeding is influenced by uncontrolled values of BP, by serum cholesterol levels, diabetes mellitus poorly controlled, smoking and alcohol abuse (13). In our patient, after initiating anticoagulant treatment, frequent neurological assessments were performed during hospital stay, to detect early signs of rebleeding.…”

“…Without anticoagulant treatment, annual recurrence rate of ICH was between 0 and 8,6%. Contrarily, recurrence rate of ICH during anticoagulant treatment is higher: 2,6 to 8.7% anualy (13). Rebleeding is influenced by uncontrolled values of BP, by serum cholesterol levels, diabetes mellitus poorly controlled, smoking and alcohol abuse (13).…”

Der zweite Blick: praktische diagnostische und therapeutische Checks in der rehabilitativen Neurologie

“…Denn relativ zu keiner Überbrückung erhöht Bridging nur das Blutungsrisiko, ohne das Thromboserisikos zu mindern [79]. Zur Gabe von Thrombozytenaggregationshemmern im Intervall bis zur Antikoagulation gibt es unterschiedliche Stellungnahmen [9,44]. Wir geben diese nur unmittelbar nach Herzinfarkt oder Stentplatzierung, aber nicht als "weniger blutungsträchtige" Zwischentherapie eines Vorhofflimmerns.…”

Resumption of oral anticoagulation after spontaneous intracerebral hemorrhage

“…While the benefit of OAC for prevention of thromboembolic complications, caused by several indications like atrial fibrillation, artificial heart valves, deep vein thrombosis and pulmonary embolism, or coagulopathies, is generally accepted, OAC resumption after ICH is mainly an issue of safety, i.e. risk of recurrent ICH [ 25 ].…”

“…The same holds true for (uncontrolled, > 140 mmHg) arterial hypertension representing a major – but importantly modifiable – risk factor especially for recurrence of ICH, increasing hazard ratios [HR] to 3.5 (95% CI(1.7–7.5), p = .001) in lobar ICH and to 4.2 (95% CI (1.0–17.5), p < .05) in non-lobar ICH [ 1 ]. Distinguishing location of index ICH is of outmost importance because of the strong relation between lobar ICH and cerebral amyloid angiopathy [ 25 ]. Lobar location increases the risk of recurrent ICH shown by longitudinal data ( n = 1145) documenting a duplication of the annual recurrence rate compared to non-lobar ICH (7.8% versus 3.4%) [ 1 ].…”