Abstract Details

Title The Reinstitution of Anticoagulation After Intracerebral Bleeding – A Meta-analysis and Literature Review

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) S9 - Cerebrovascular Disease: Intracerebral Hemorrhage (5:06 PM-5:18 PM)

Poster/Presentation
Number 009

Objective The objective of this meta-analysis is to understand the benefits and harms of re-starting the anticoagulation after intracranial bleeding in patients with high risk of embolic disease.

Background The question of resuming oral anticoagulation (OAC) after intracerebral bleed [ICH] remains unanswered and has been subjective based on clinical discretion in different settings. We have performed a systematic review and meta-analysis to understand the safety of resuming anticoagulation after ICH following the future risk of recurrent ICH or thromboembolism.

Design/Methods

We searched published medical literature using EMBASE, PubMed, Cochrane databases to identify cohort, randomized controlled trials, systematic reviews and meta-analysis involving the adults with anticoagulation-associated ICH. Primary outcomes were measures of thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. The secondary outcome was measured in terms of mortality. The strength of association between anticoagulation resumption and outcomes were assessed using random effects model.

Results Total of 17,493 patients in 6 cohorts and one meta-analysis were analyzed. OAC can be safely started within 4-8 weeks of ICH. No clear benefit of the re-institution of OAC <2 weeks was observed [p=0.212]. There is a clear mortality benefit but recurrence of ICH increased after resuming OAC (HR, 0.29; 95% CI, 0.17–0.45). There was significant heterogeneity among included studies (pooled relative risk, 1.02; 95% confidence interval, 0.55–1.67; Q=23.57, P for heterogeneity <0.001). Lobar hemorrhage has a higher ICH recurrent rate compared with hemorrhage in a deep cortical location (22 vs. 4% for cumulative 2-year rate, p=0.007). There was an attrition bias in multiple studies but not significant enough to affect the outcomes.

Conclusions

Re-initiation of OAC after ICH is associated with lower mortality, thromboembolism and recurrent ICH. Both early (< 2 weeks) and late (> 4 weeks) resumption should be done only after a considerate evaluation of risks for ICH recurrence and thromboembolism.

Authors/Disclosures
Salman Assad, MD, MBBS PRESENTER	Dr. Assad has nothing to disclose.
Justin M. Nolte, MD	Dr. Nolte has nothing to disclose.
Samrina Hanif, MD	Dr. Hanif has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for LivaNova .
Paul B. Ferguson, MD, FAAN (Marshall University)	Dr. Ferguson has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Horizon. Dr. Ferguson has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen. Dr. Ferguson has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Genentech. Dr. Ferguson has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Janssen. Dr. Ferguson has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Allergan.

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