Safety of Anticoagulation in Patients With an Intracranial Hemorrhage at a Comprehensive Stroke Center

Background: Approximately 10% to 15% of patients who suffer intracranial hemorrhages (ICHs) are on therapeutic anticoagulation. Additionally, patients may develop an indication for anticoagulation after ICH. There is minimal guidance with starting anticoagulation after an ICH, and most evidence has evaluated vitamin K antagonists (VKA). Objective: The aim of this study was to evaluate the safety of anticoagulation prescribing following a nontraumatic ICH with VKA, low molecular weight heparin (LMWH), or direct oral anticoagulants (DOACs). Methods: A retrospective chart review was conducted of patients admitted with a nontraumatic ICH and an indication for anticoagulation between February 2015 to June 2018 at an urban tertiary comprehensive stroke center. The primary objective was to evaluate the safety of prescribing anticoagulation in these patients. Two groups were reviewed to evaluate the primary outcome: patients who were started on anticoagulation after ICH (anticoagulation group) and a comparator group not started on anticoagulation (control group). The primary endpoint was measured by a composite incidence of recurrent ICH, major bleeding events, and thromboembolic events. Results: Anticoagulation was started within 2 months in 23 patients with an indication for anticoagulation. Anticoagulation was held in 35 patients. There was no difference in the composite primary endpoint between the 2 groups (P = .29). The median time to starting anticoagulation was 21 days (IQR 7-28 days). Conclusions: This study shows the safety of starting anticoagulation in patients with recent ICH in our cohort of patients and highlights the need for more robust evidence to guide clinical decision making.