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Acute Management Of Anticoagulation-Associated Intracerebral Hemorrhage

Joji Kuramatsu, Stefan Gerner, Hagen Huttner, Stefan Schwab
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AbstractThe incidence of anticoagulation-associated intracerebral hemorrhage (OAC-ICH) is increasing along with demographic changes and patients requiring oral anticoagulation for atrial fibrillation. OAC-ICH is one of the most detrimental sub-types of hemorrhagic stroke, characterized by larger hemorrhage volumes, more frequent intraventricular hemorrhage, increased and prolonged hematoma enlargement. The impact of these outcome predictors’ results in greater mortality rates and larger numbers of patients left in functionally dependent states after ICH. Yet, evidence on treatment options for these severely affected patients remains limited, resulting in weak recommendations by international and European guidelines. Minimization of hematoma enlargement constitutes the main focus of acute care, possibly achieved by blood pressure and reversal management. In all OAC-ICH patients irrespective of anticoagulation agent, immediate and aggressive blood pressure reductions as fast as possible targeting systolic blood pressure levels of 140 mmHg (at least within 4–6 h) seems reasonable. Specifically, in vitamin-K-associated ICH, blood pressure reductions have been shown to be associated with reduced rates of hematoma enlargement. Reversal management in OAC-ICH should be carried out as quickly as possible, though accounting for the different anticoagulation agents used. In vitamin-K-associated ICH, recent large-sized multicenter investigations contributed to refining reversal strategies. One German-wide cohort study including roughly 1 200 patients identified for the first time beneficial target values to guide reversal treatment. Anticoagulation reversal should achieve INR values of less than 1.3 or 1.2 at least within 4 h after admission. Agents to be used comprise prothrombin complex concentrates (PCC), which may achieve faster and more complete reversal. This combined approach (blood pressure management and INR-reversal) was associated with significant reductions of hematoma enlargement and lower in-hospital mortality rates. For dabigatran-related bleeding complications, most recently an antidote (Idarucizumab) has been approved, which has been prospectively investigated and showed rapid and almost complete reversal as well as sufficient hemostasis. Currently, bleeding under the influence of factor-Xa inhibitors poses great difficulties because no antidote is available and efficacy of commonly used antagonizing agents, i. e., PCC or fresh-frozen plasma (FFP), has not been proven for clinical use. The main aim of the present review focuses on acute-care management of OAC-ICH and tries to depict treatment options based on the most current data. Moreover, current neurocritical-care therapies for ICH will be reviewed to identify relevant implications specific to OAC-ICH treatment.