The Dilemma of Resuming Anticoagulation After Intracranial Hemorrhage

Abstract

Intracranial hemorrhage (ICH) is the most feared and devastating complication of anticoagulant treatment, leading to death or disability in two thirds of cases. Once ICH occurs, the decision of whether to resume anticoagulation is a true therapeutic dilemma that requires balancing the competing risks of hematoma growth or recurrent ICH and disabling thromboembolic events. Although the risk of thromboembolism in patients off anticoagulation is higher than the overall risk of ICH recurrence, there is a marked paucity of prospective large population-based data on the real risk of ICH recurrence on warfarin. The lack of randomized controlled trials probably reflects the ethical challenge of prescribing patients a medication to which they have an apparent contraindication. Therefore, in clinical practice, the risk is usually, and inappropriately, extrapolated from the overall risk of major bleeding on warfarin (approximately 3%), in which older age and elevated international normalized ratio are factors associated with an increased risk. The little evidence available on resuming oral anticoagulation after ICH comes from either expert opinions or few nonrandomized mainly retrospective studies.1,2 These studies included highly selected high-risk patients and showed nonconclusive and even discrepant results. This limited and weak evidence along with our own …