Abstract
Direct oral anticoagulants (DOAC) are widely used due to their benefits of reducing the risk of systemic embolism and cardioembolic ischemic stroke in patients with atrial fibrillation and other conditions. However, DOACs increase the risk of bleeding compared to no antithrombotic treatment, although to a lesser degree compared to Vitamin K antagonists. Intracerebral hemorrhage (ICH) is a devastating disease. Its incidence and mortality is projected to remain stable in Europe until 2050 1 despite current efforts for better control of vascular risk factors (i.e. arterial hypertension). Contemporary data show that about 1 out of 5 patients with ICH is on active therapeutic anticoagulation at the time of bleeding onset and that the spectrum of anticoagulation shifted from Vitamin K antagonists to DOACs, mainly factor Xa inhibitors, in recent years.2,3 The same data suggest that outcome in those patients is poor with a mortality of over 40% and less than 25% of patients being independent at 3 months. 3
Acute treatment of intracerebral hemorrhage should follow a structured approach using care bundles 4 including blood pressure control, anticoagulation reversal and a care pathway for neurosurgical referral, and other components of organized stroke care. Current treatment strategies for DOAC-associated ICH focus on limiting hematoma expansion by reversing the anticoagulant effect using specific reversal agents.5,6
In this special issue of the European Stroke Journal, we present five state-of-the art reviews on recent advances and clinical management of anticoagulation-associated intracerebral hemorrhage.
The first article introduces key concepts of hematoma expansion and the principles of anticoagulation reversal. The second paper reviews and discusses the currently available data on various reversal agents, evaluating the quality of evidence from clinical trials. A comprehensive, up-to-date review of anticoagulant activity monitoring in the acute setting is provided in the third article, alongside a discussion of blood pressure management—a critical component of ICH treatment. The issue concludes with an exploration of current practices and future directions regarding the re-initiation of oral anticoagulation in patients with atrial fibrillation and a history of intracerebral hemorrhage.
