Antithrombotic medicines following intracerebral haemorrhage: where's the evidence?

The use of antithrombotic medicines in patients who have a history of intracerebral haemorrhage is widely perceived as being contraindicated. However, many patients with intracerebral haemorrhage may suffer from conditions for which antithrombotic medicines are indicated. Such scenarios represent a therapeutic dilemma whereby treating infers an increased risk of recurrent intracerebral haemorrhage, but not treating infers an increase of thrombotic complications. Despite the importance of this dilemma, there is very little guidance for prescribers. This perspective review considered previous systematic reviews that addressed this issue, together with recently published research findings from the Tayside Stroke Cohort. Systematic reviews of experimental and observational studies have concluded that there is a marked lack of data on which to judge the safety of oral anticoagulant agents following intracerebral haemorrhage. In addition, the limited data available regarding the use of antiplatelet medicines following intracerebral haemorrhage provide no evidence that they are harmful, and again further data are required. In the absence of such data, a decision analysis approach has been proposed. This considers the findings of other studies to infer the likely impact of using antithrombotic agents in patients with intracerebral haemorrhage. The success of this approach is contingent on the availability of reliable data that describe the rate of recurrent intracerebral haemorrhage; however, published data on this varies widely. There are a number of factors that conspire against researchers addressing this issue. The current paucity of evidence to guide prescribers faced with this therapeutic dilemma seems likely to remain for some time.