Resumption of Oral Anticoagulation After Warfarin-Associated Intracerebral Hemorrhage

Steiner, Thorsten

doi:10.1161/strokeaha.111.621797

Cited by 25 publications

(18 citation statements)

References 7 publications

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“…1 Still, a large proportion of these patients are untreated, reflecting the controversy of the decision. [2][3][4][5] There is emerging evidence of the potential benefits of anticoagulants in these patients. In a Swedish population-based study, recurrent ischemic events outnumbered recurrent ICH among ICH survivors 6 and ICH in itself has been identified as an independent predictor of thromboembolic events among patients with AF.…”

mentioning

confidence: 99%

Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation

Pennlert

Overholser

Asplund

et al. 2017

Stroke

107

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Using the nationwide Swedish Stroke Register, Riksstroke, we studied the relationship between the timing Background and Purpose-This study aims to provide observational data on the relationship between the timing of antithrombotic treatment and the competing risks of severe thrombotic and hemorrhagic events in a cohort of Swedish patients with atrial fibrillation and intracerebral hemorrhage (ICH). Methods-Patients with atrial fibrillation and a first-ever ICH were identified in the Swedish Stroke Register, Riksstroke, 2005Riksstroke, to 2012. Riksstroke was linked with other national registers to find information on treatment, comorbidity, and outcome. The optimal timing of treatment in patients with low and high thromboembolic risk was described through cumulative incidence functions separately for thrombotic and hemorrhagic events and for the combined end point vascular death or nonfatal stroke. Results-The study included 2619 ICH survivors with atrial fibrillation with 5759 person-years of follow-up. Anticoagulant treatment was associated with a reduced risk of vascular death and nonfatal stroke in high-risk patients with no significantly increased risk of severe hemorrhage. The benefit seemed to be greatest when treatment was started 7 to 8 weeks after ICH. For high-risk women, the total risk of vascular death or stroke recurrence within 3 years was 17.0% when anticoagulant treatment was initiated 8 weeks after ICH and 28.6% without any antithrombotic treatment (95% confidence interval for difference, 1.4%-21.8%). For high-risk men, the corresponding risks were 14.3% versus 23.6% (95% confidence interval for difference, 0.4%-18.2%). Conclusions-This nationwide observational study suggests that anticoagulant treatment may be initiated 7 to 8 weeks after ICH in patients with atrial fibrillation to optimize the benefit from treatment and minimize risk.

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mentioning

confidence: 99%

Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation

Pennlert

Overholser

Asplund

et al. 2017

Stroke

107

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“…After intracerebral haemorrhage in deep parts of the brain (basal ganglia, thalamus), cerebellum or brainstem (figure 1), the mean yearly risk of recurrent bleeding is 2%–4% 14 15. Patients with such haemorrhage often have a history of hypertension, mainly affecting small perforating arteries with relatively little decay of blood pressure in the course of the artery 14 15. Superficially located haemorrhages (‘lobar haematomas’, figure 2) are more often caused by cerebral amyloid angiopathy, affecting small arteries, arterioles, capillaries and veins in the cortex and leptomeninges.…”

Section: After the Acute Phase: Resumption Of Antithrombotics?mentioning

confidence: 99%

Antithrombotic treatment and intracerebral haemorrhage: between Scylla and Charybdis

2015

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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.

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“…The European stroke initiative suggests balancing the risk of recurrent ICH and thromboembolism in individuals with a strong indication for anticoagulation, and reinitiating the latter 10 to 14 days after the incident WRICH [64]. Practically, resumption of anticoagulation is debated among stroke experts and most agree to restart anticoagulation in 7 to 14 days provided benefits outweigh the risk and if the hemorrhage was deep in location [121]. …”

Section: Resumption Of Anticoagulationmentioning

confidence: 99%

Management of anticoagulant-related intracranial hemorrhage: an evidence-based review

Ray

Keyrouz

2014

Crit Care

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The increased use of anticoagulants for the prevention and treatment of thromboembolic diseases has led to a rising incidence of anticoagulant-related intracranial hemorrhage (AICH) in the aging western population. High mortality accompanies this form of hemorrhagic stroke, and significant and debilitating long-term consequences plague survivors. Although management guidelines for such hemorrhages are available for the older generation anticoagulants, they are still lacking for newer agents, which are becoming popular among physicians. Supportive care, including blood pressure control, and reversal of anticoagulation remain the cornerstone of acute management of AICH. Prothrombin complex concentrates are gaining popularity over fresh frozen plasma, and reversal agents for newer anticoagulation agents are being developed. Surgical interventions are options fraught with complications, and are decided on a case-by-case basis. Our current state of understanding of this condition and its management is insufficient. This deficit calls for more population-based studies and therapeutic trials to better evaluate risk factors for, and to prevent and treat AICH.

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Resumption of Oral Anticoagulation After Warfarin-Associated Intracerebral Hemorrhage

Cited by 25 publications

References 7 publications

Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation

Optimal Timing of Anticoagulant Treatment After Intracerebral Hemorrhage in Patients With Atrial Fibrillation

Antithrombotic treatment and intracerebral haemorrhage: between Scylla and Charybdis

Management of anticoagulant-related intracranial hemorrhage: an evidence-based review

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