Acute Management of Intracerebral Hemorrhage in Patients with Anticoagulation Therapy

Anticoagulation-associated intracerebral hemorrhage is a complex clinical emergency with high rates of morbidity and mortality. The increasing use of anticoagulants, particularly in elderly populations with conditions like atrial fibrillation or mechanical heart valves, has contributed to a growing number of spontaneous ICH cases. Management in the acute phase requires rapid identification of the anticoagulant involved, immediate reversal of its effects, and stabilization of the patient's neurological condition. Prothrombin complex concentrates, vitamin K, idarucizumab, and andexanet alfa are among the primary agents used, with selection depending on drug class and availability. Delays in reversal therapy are associated with increased hematoma expansion and worse functional outcomes. Clinical judgment is critical in balancing the urgency of reversal with the potential risks of thrombosis, especially in patients with significant cardiovascular comorbidities. The decision to resume anticoagulation following AAICH remains one of the most challenging aspects of long-term management. Observational studies suggest that resuming anticoagulation between 7 and 14 days after the initial event may offer protection against thromboembolism without significantly increasing the risk of recurrent bleeding. Timing often depends on hematoma location, radiographic stability, and the indication for anticoagulation. Predictors of poor outcome include low Glasgow Coma Scale scores, large hematoma volume, intraventricular extension, and lobar location. Post-discharge recovery is influenced by age, comorbidities, and access to rehabilitation services. Patients who receive early follow-up and structured care show better functional independence and reduced readmission rates. Optimizing both acute interventions and long-term planning is essential for improving survival and quality of life in this high-risk population.