Resuming anticoagulants after anticoagulation-associated intracranial haemorrhage: systematic review and meta-analysis

Abstract

ObjectiveTo determine the adverse outcomes following resumption of anticoagulation in patients with anticoagulation-associated intracranial haemorrhage (ICH).DesignWe performed a systematic review and meta-analysis in this clinical population. The Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement was followed, and two authors independently assessed eligibility of all retrieved studies and extracted data.Data sourcesMedline, Embase and the Cochrane Central Register of Controlled Trials, from inception to February 2017.Eligibility criteria and outcomesRandomised controlled trials or cohort studies that recruited adults who received oral anticoagulants at the time of ICH occurrence and survived after the acute phase or hospitalisation were searched. Primary outcomes, including long-term mortality, recurrent ICH and thromboembolic events. Secondary outcomes were the frequency of resuming anticoagulant therapy and related factors.ResultsWe included 12 cohort studies (no clinical trials) involving 3431 ICH participants. The pooled frequency of resuming anticoagulant therapy was 38% (95% CI 32% to 44%), but this was higher in participants with prosthetic heart valves, subarachnoid haemorrhage or dyslipidaemia. There was no evidence that resuming anticoagulant therapy was associated with higher long-term mortality (pooled relative risk (RR) 0.60, 95% CI 0.30 to 1.19; p=0.14) or ICH recurrence (pooled RR 1.14, 95% CI 0.72 to 1.80; p=0.57). Resumption of anticoagulation was associated with significantly fewer thromboembolic events (pooled RR 0.31, 95% CI 0.23 to 0.42; p<0.001). In a subgroup of patients with atrial fibrillation, resuming anticoagulant therapy was associated with fewer long-term mortality (pooled RR 0.27, 95% CI 0.20 to 0.37, p<0.001).ConclusionsBased on these observational studies, resuming anticoagulant therapy after anticoagulation-associated ICH has beneficial effects on long-term complications. Clinical trials are needed to substantiate these findings.PROSPERO registration numberCRD42017063827.

Treating Venous Thromboembolism Post Intracranial Hemorrhage: A Case Report

“…It was decided that despite the history of multiple PEs, anticoagulation therapy should be stopped acutely and an IVC filter was placed while treatment was pursued for the CCM. Current guidelines according to the American Heart Association suggest that anticoagulation could be resumed four weeks post-ICH but there seems to be a lack of consensus regarding this topic [17,18].…”

“…This case also highlights the need for systematic studies to better outline when to restart anticoagulation per specific risk factors (especially location) post ICH. While the American Heart Association suggests four weeks post ICH to resume anticoagulation, a meta-analysis by Zhou et al suggested there is still no firm time table when to resume therapy and further studies are needed [18].…”

Management of oral anticoagulation after intracerebral hemorrhage

“…17 Summing up these data several meta-analyses of aggregate data reported that resuming OAC was associated with significant reductions of thromboembolic events and/or ischemic stroke whereas bleeding complications and/or recurrence of intracranial hemorrhages were not significantly increased. 25–28 Further, the use of antiplatelet agents did not confer benefit neither for prevention of ICH recurrence nor protection from ischemic events.…”

Resumption of oral anticoagulation after spontaneous intracerebral hemorrhage

“…Several meta-analyses of reported data have been conducted until now, all of them showing a significant reduction of thromboembolic complications without leading to increased risk of ICH recurrence [ 3 , 22 , 30 , 57 ]. Furthermore, antiplatelet agents – sometimes considered as a safer alternative approach – were not beneficial neither for thromboembolism prophylaxis nor prevention of ICH recurrence [ 22 ].…”