Reversing the trend: interventions to treat intracranial haemorrhage associated with anticoagulation.

Abstract

Spontaneous intracranial haemorrhage (ICH) is less common as a cause of stroke than ischaemia, but it has significantly worse morbidity and mortality. To some extent this reflects, the different demographics of the populations affected, but a lack of effective therapeutic options is also a contributory factor. Whilst ICH as a result of underlying vascular malformations or other structural lesions offers certain neuroradiological and/or neurosurgical possibilities to prevent recurrence, interventions to reverse damage caused by the index event remain limited regardless of aetiology. As a result, current management is mainly supportive and includes reversal of anticoagulation where appropriate, blood pressure control, prevention of hyperglycaemia and pyrexia, and the treatment of emergent complications, such as seizures. Anticoagulant and antiplatelet medications are often associated with ICH and adversely affect outcome. Patients are treated with these agents for a variety of reasons, including primary or secondary prevention of cardiac and cerebral ischaemic events. Historically, there has been a choice been between aspirin (or other antiplatelet agents) or a coumarin. However, recently a number of new agents have been developed (novel oral anticoagulants—NOACs), and have potential advantages over Warfarin, including a lower risk of haemorrhagic complications for an equivalent level of thrombo-embolic risk reduction and the lack of requirement for international normalised ratio (INR) monitoring. However, none of the NOACs has a specific agent to reverse their action in the event of haemorrhagic complications. This month, journal club focuses on reversal of drugs which contribute to or have the potential to worsen ICH. The first paper reports a randomised-controlled trial of platelet infusion versus the standard care in patients with ICH on antiplatelet agents. The second paper is a randomised-controlled trial of fresh frozen plasma versus prothrombin complex concentrate in the reversal of warfarin-associated ICH. Finally, we review an observational study of ICH associated with NOACs, focussing on prognostic factors and effectiveness of haemostatic treatments.