Danny R. Rose, Jr., MD
For most clinicians, intracerebral hemorrhage (ICH) is the most feared potential complication of anticoagulation therapy, carrying significant morbidity and mortality. Clinical decision-making regarding the resumption of anticoagulation for patients for whom it is indicated is complex, as many of these patients have significant risk of ischemic and hemorrhagic events. Traditionally, providers have been reluctant to restart anticoagulation after ICH, especially for patients with atrial fibrillation as compared to mechanical valves.
AHA guidelines reflect the lack of clarity on this matter, with current recommendations (Class IIa) to avoid anticoagulation after spontaneous lobar ICH in patients with non-valvular atrial fibrillation (NVAF), and to consider resuming antiplatelet therapy after all ICH and anticoagulation in patients with non-lobar ICH (Class IIb). Selection and timing for resumption of anticoagulation has been the topic of ongoing research, with the results of pertinent studies presented at the International Stroke Conference, as well as the European Stroke Organisation Conference in 2017. In addition to this, a recent meta-analysis published in Stroke by Drs. Murthy et al. sought to address this clinical challenge by reviewing available studies with respect to the safety and efficacy of restarting anticoagulation after ICH. To understand the significance of this study in the context of evolving concepts regarding anticoagulation after ICH, we will start by reviewing a previous study with similar aims.