Antithrombotic Treatment After Stroke Because Of Intracerebral Hemorrhage
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
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.
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.
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.
This article is based on a Cochrane Review published in The Cochrane Library 2017, Issue 5 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review. URL: http://dx.doi.org/10.1002/14651858.CD012144.
Eivind Berge is a coordinating investigator of the planned STATICH trial (Study of Antithrombotic Treatment After Intracerebral Haemorrhage). Elisabeth Forfang is a managing investigator of the planned STATICH trial. Rustam Al-Shahi Salman is a chief investigator of the UK REstart or STop Antithrombotics Randomised Trial (RESTART; www.RESTARTtrial.org, ISRCTN71907627). The other authors report no conflicts.
- Received June 20, 2017.
- Revision received June 20, 2017.
- Accepted June 27, 2017.
- © 2017 American Heart Association, Inc.