European Stroke Organisation Conference (ESOC)
May 16–18, 2017

May 18, 2017
Should you restart anticoagulation after a cerebral haemorrhage? And other questions.

There are few things as devastating as a large ischaemic stroke in a patient who you had previously advised not to take anticoagulation.

As a stroke physician, I’ve been asked questions about whether I should give anticoagulation to a patient who has had an intracerebral haemorrhage (ICH). Many people who have had an ICH are at high risk of having an ischeamic stroke. At the late-breaking trials session of ESOC, there was some useful evidence that will help me sleep after these consults.

Dr. Joji Kuramatsu presented data from an individual patient meta-analysis from two observational studies of patients with ICH. 1,027 people had an ICH caused by anticoagulation. This was an interesting choice of patient group; in my experience, these people are often very reluctant to consider restarting the drug which caused their stroke, but they had managed to convince 267 of them to restart anticoagulation. Fortunately, those patients that restarted anticoagulation had decreased mortality and all cause stroke.

More reassurance came from Dr. Eleni Korompoki, who presented an excellent systematic review and meta-analysis of studies of anticoagulation or antiplatelets after intracerebral haemorrhage. They identified seven observational studies of 2,452 patients, and found no increase in ICH or mortality in the patients given antiplatelets.

This is all very encouraging, but you have to be cautious about observational studies. Patients resuming anticoagulation may well have fitter and had smaller bleeds. Although I feel a little reassured about starting antiplatelets in these patients, I’d be more reassured by an RCT, and I’m eagerly awaiting the results of the ones that are ongoing.

—Stephen Makin, PhD