Antithrombotic treatment after stroke because of intracerebral hemorrhage

Luke A. Perry, Eivind Berge, Joshua Bowditch, Elisabeth Forfang, Ole Morten Ronning, Graeme J. Hankey, Elmer Villanueva, Rustam Al-Shahi Salman

Research output: Contribution to journalEditorialpeer-review


Many survivors of stroke because of intracerebral hemorrhage (ICH) are at risk of ischemic vascular disease. Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of ischemic events after ICH, but they may increase the risks of bleeding.


To determine the overall effectiveness and safety of antithrombotic drugs for secondary prevention after ICH.1


Search Methods

We searched the Cochrane Stroke Group Trials Register (March 24, 2017), the CENTRAL (Cochrane Central Register of Controlled Trials: the Cochrane Library 2017, Issue 3), Ovid Medline (from 1948 to March 2017), Ovid Embase (from 1980 to March 2017), and online registries of clinical trials (March 8, 2017). We also screened the reference lists of included trials for additional, potentially relevant studies.

Selection Criteria

We selected all randomized controlled trials (RCTs) of any antithrombotic treatment versus no antithrombotic treatment for short- or long-term secondary prevention of ischemic events after ICH.

Data Collection and Analysis

Three review authors independently extracted data and assessed the included RCTs for risk of bias. We calculated the risk ratio (RR) or odds ratio, as appropriate, and used fixed-effect modeling for meta-analyses.

Main Results

We included 2 RCTs with a total of 121 participants. Both RCTs were of short-term parenteral anticoagulation early after ICH: one tested heparin and the other enoxaparin. The risk of bias in the included RCTs was generally unclear or low. The included RCTs did not report our chosen primary outcome (a composite of all serious vascular events including ischemic stroke, myocardial infarction, other major ischemic event, ICH, major extracerebral hemorrhage, and vascular death). Parenteral anticoagulation did not significantly affect case fatality (RR, 1.25; 95% confidence interval, 0.38–4.07 in one of the trials involving 46 participants), ICH, or major extracerebral hemorrhage (no detected events in of the trials involving 75 participants), growth of ICH (RR, 1.64; 95% confidence interval, 0.51–5.29 in both trials involving 121 participants), deep vein thrombosis (RR, 0.99; 95% confidence interval, 0.49–1.96 in both trials involving 121 participants), or major ischemic events (RR, 0.54; 95% confidence interval, 0.23–1.28 in both trials involving 121 participants). The literature search identified 6 trials that are ongoing or ready to start recruitment (see full review).


There is insufficient evidence from RCTs to support or discourage the use of antithrombotic treatment after ICH. RCTs comparing starting versus avoiding antiplatelet or anticoagulant drugs after ICH appear justified and are needed in clinical practice.
Original languageEnglish
Pages (from-to)e247
Issue number9
Publication statusPublished - Sep 2017


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