Restarting Anticoagulants After Intracranial Hemorrhage

Study Questions:

What is the safety and efficacy of restarting anticoagulation after intracerebral hemorrhage (ICH)?


Published medical literature was searched to identify studies involving adults with anticoagulation-associated ICH. The predictor variable was resumption of anticoagulation. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, a meta-analysis using random-effects models was performed to assess the strength of association between anticoagulation resumption and outcomes.


Eight studies were eligible for inclusion in the meta-analysis, with 5,306 ICH patients. Almost all studies evaluated anticoagulation with vitamin K antagonists. Reinitiation of anticoagulation was associated with a significantly lower risk of thromboembolic complications (pooled relative risk, 0.34; 95% confidence interval, 0.25–0.45; Q = 5.12, p for heterogeneity = 0.28). There was no evidence of increased risk of recurrent ICH after reinstatement of anticoagulation therapy, although there was significant heterogeneity among included studies (pooled relative risk, 1.01; 95% confidence interval, 0.58–1.77; Q = 24.68, P for heterogeneity < 0.001). No significant publication bias was detected in the analyses.


In observational studies, reinstitution of anticoagulation after ICH was associated with a lower risk of thromboembolic complications and a similar risk of ICH recurrence.


There are no randomized clinical studies on the safety and efficacy of resuming anticoagulation in patients who experienced an ICH while anticoagulated. The decision on whether and when to resume anticoagulation is based on several clinical factors, such as the size and location of the hemorrhage, the recurrence rate of the particular type of ICH, the underlying indication for anticoagulation, and social factors. The confounders abound, as much of this information was unavailable to the investigators, or not consistently reported. Most of all, the decision to resume anticoagulation made by the clinicians most certainly preselected patients who were thought to be at lower risk of re-bleeding. Finally, the meta-analysis does not provide any guidance on how soon anticoagulation should be restarted. The paucity of high-quality studies on this subject is a clear indication of a need for a number of prospective clinical trials testing the hypothesis in a variety of clinical circumstances.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Arrhythmias, Cardiac, Anticoagulants, Atrial Fibrillation, Cerebral Hemorrhage, Geriatrics, Intracranial Hemorrhages, Primary Prevention, Stroke, Myocardial Infarction, Outcome Assessment (Health Care), Risk, Stroke, Thromboembolism, Vascular Diseases, Vitamin K

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