Abdel Salam R. Kaleel M.D, MSc

Pasquini M, Charidimou A, van Asch CJJ, Baharoglu MI, Samarasekera N, Werring DJ, et al. Variation in Restarting Antithrombotic Drugs at Hospital Discharge After Intracerebral Hemorrhage. Stroke. 2014

Restarting antithrombotic therapy following an intracerebral hemorrhage (ICH) has been the subject of much controversy and debate over the years. This is especially true as an increasing number of patients are prescribed antithrombotics for atrial fibrillation or thrombo-embolic disease. However, little data is currently available to support the establishment of definitive guidelines for these patients with most recommendations suggesting an individualized approach for each patient. 

With that in mind, this study was designed to assess the variation in restarting antithrombotic drugs by comparing the characteristics and proportions of patients taking antithrombotic drugs at ICH onset and discharge in four hospital-based cohorts in France, the Netherlands, and in the United Kingdom using bivariate and multivariable logistic regression analysis.A total of 2138 patients, median age 72 years, 53% male) were reviewed in this study, 942 of whom were taking antithrombotics at presentation- 559 of them taking antiplatelets prior to ICH, 333 taking Vitamin K antagonists, and 50 taking both. Exclusion criteria included patients with purely extra-axial hemorrhage, patients treated with heparin, or patients with a secondary cause of ICH such as vascular malformation. 

Data was collected on each patient, a study investigator with stroke expertise analyzed the images for classification into the various groups (lobar, non-lobar, unclassifiable, or multiple), and antithrombotic drug was categorized by type (antiplatelet, antithrombotic, or both). Case fatality rate was recorded at 30 days. Patients taking antithrombotic drugs had higher case fatality rate at 30 days, overall, when compared to patients not taking antithrombotics. Bivariate analysis revealed that restarting antithrombotics was more likely in younger patients, but median ICH volume was not found to differ between survivors who restarted or stopped antithrombotic agents. The proportion of patients restarting was also highest in those who were taking vitamin K antagonists before ICH. The strengths of the study included the large sample size and inclusion of multiple cohorts representing different settings. The variation between patients suggested that the cohort of origin played a role and the authors recommended that further studies be carried out to determine the best approach to guide future treatment plans.