Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review

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Dimitrios Giakoumettis
Dimitrios A. Vrachatis
Dimitrios Panagopoulos
Asimina Loukina
Georgios Tsitsinakis
Katerina Apostolopoulou
Georgios Giannopoulos
Sotiria Giotaki
Spyridon Deftereos
Marios S. Themistocleous


ICH, antiplatelets, antithrombotic agents, anticoagulation, thromboembolism


Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin—novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease. The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy.

We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy. Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.
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