Oral anticoagulation related intracerebral hemorrhage: more questions than answers

Intracranial hemorrhage (ICH) is the most feared and devastating complication of oral anticoagulant therapy. When an ICH occurs, the patient’s situation hinges on the balance between how great is the embolic risk while not receiving anticoagulants, and how big is the threat of the hemorrhage if the anticoagulant effect is not reversed promptly. Although several studies which compared the use of different reversal agents failed to demonstrate any improvement in prognosis and survival, at the present moment the consensus seem to be that anticoagulation should be rapidly reversed after an ICH. The second question to be answered is whether and when should be oral anticoagulation treatment restarted. Although the risk of thromboembolism in patients off anticoagulation seems to be higher than the risk of ICH recurrence, there is a marked paucity of prospective large studies on the real risk of ICH recurrence when OAC is resumed, paucity that probably emphasizes the ethical challenge of prescribing patients a medication to which they have an apparent contraindication. The little evidence available suggests that the optimal time for resumption is between 10 days and 30 weeks.