Antithrombotic Therapy After Cerebral Hemorrhages

Abstract

To the Editor: Oral anticoagulation (OAC) generally increases the likelihood of intracerebral hemorrhage (ICH). When there is an indication for OAC in a patient with a history of ICH, the clinician is in the difficult situation of assessing risks and benefits of OAC. In the absence of data from clinical trials, Eckman et al1 have used a decision-analysis model to compare the expected values of 3 treatment strategies—OAC, aspirin, and no antithrombotic therapy—in patients with ICH and atrial fibrillation (AF).1 They conclude that all survivors of lobar ICH and most survivors of deep hemispheric ICH with AF should not be offered OAC. Only patients with deep hemispheric ICH at high risk for stroke or embolism or low risk of ICH recurrence might benefit from OAC.1 Before these recommendations are integrated into clinical practice, several assumptions in the decision-analysis model have to be clarified: 1. The origin of ICH is multifactorial. Some underlying pathologies such as vascular malformations or vasculitis are treatable. For others, no causal treatment is available. Cause and treatment influence the recurrence rate of ICH. Thus, in a patient with ICH and indication for OAC, the ICH origin has to be assessed, as does whether there was any kind of treatment. We miss this kind of evaluation in the model assumptions. Possibly, the assumption is that all “secondary” causes of ICH like vascular malformations, tumors, hemorrhagic infarcts, trauma, and vasculitis have been definitively excluded. If this is the case, it should be stated. 2. For patients with lobar ICH, a high annual recurrence rate of 15% is assumed on the basis of 1 study with 71 patients that also included patients with a previous ICH before the index ICH.2 This rate is much higher than the 0.0% to 5.7% reported by other studies.3 …