Antithrombotic Therapy After Intracerebral Hemorrhage: Real-World Evidence for In-Hospital Resumption

Patients with intracerebral hemorrhage (ICH) who require antithrombotic therapy (AT) face competing risks of recurrent bleeding and ischemic events. Optimal timing of AT resumption during hospitalization remains uncertain. We evaluated whether restarting AT in hospitalized patients with acute spontaneous ICH reduces ischemic complications without increasing hemorrhagic risk.

We conducted a retrospective cohort study at Peking Union Medical College Hospital (2014-2022) including adults (≥ 18 years) admitted with spontaneous ICH within 6 months of onset. Patients were categorized as: Group 1, no AT indication; Group 2, AT indicated but not treated; Group 3, AT indicated and treated. Primary endpoints were ischemic events (ischemic stroke, transient ischemic attack, myocardial infarction, pulmonary embolism, deep venous thrombosis) and hemorrhagic events (new ICH or hematoma expansion ≥ 12.5 mL or ≥ 33%). Outcomes were assessed from onset to discharge.

Among 601 patients (median age 58 years; 40.3% female), 256 (42.6%) were in Group 1, 247 (41.1%) in Group 2, and 98 (16.3%) in Group 3. Median time from onset to AT resumption was 11 days (IQR 2-27). Restarting AT (Group 3) significantly reduced ischemic events (14.3% vs. 28.7%; adjusted HR 0.34, 95% CI 0.18-0.65) without increasing hemorrhagic events (5.1% vs. 6.3%; adjusted HR 0.67, 95% CI 0.20-2.19). Competing-risk models and sensitivity analysis confirmed these findings.

In-hospital resumption of AT after acute spontaneous ICH significantly decreased ischemic events without excess hemorrhagic risk, supporting its potential benefit in carefully selected patients.