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The use of antithrombotic therapy in patients with an acute or prior intracerebral hemorrhage

Eelco FM Wijdicks, MD
Section Editor
Jose Biller, MD, FACP, FAAN, FAHA
Deputy Editor
Janet L Wilterdink, MD


The use of antithrombotic therapies to prevent thromboembolism in patients with an acute or prior intracerebral hemorrhage (ICH) presents a clinical dilemma with competing risks and benefits. In many cases, clinical decisions must be made on the basis of indirect and observational evidence rather than high quality clinical trials.

This topic review discusses anticoagulant and antiplatelet therapy for the prevention or treatment of thromboembolic in patients with an acute or prior ICH. The overall risk, diagnosis, and treatment of warfarin-associated ICH are presented separately; other aspects of secondary prevention are also discussed separately. (See "Risk of intracerebral bleeding in patients treated with anticoagulants" and "Reversal of anticoagulation in warfarin-associated intracerebral hemorrhage" and "Spontaneous intracerebral hemorrhage: Treatment and prognosis", section on 'Secondary prevention'.)


Hematoma expansion — Intracerebral hemorrhages (ICHs) frequently expand after presentation. This phenomenon is more common in patients who have been taking antithrombotic therapy and is also associated with worse outcomes.

Serial CT scans in patients with ICH have shown that significant hematoma growth (eg, a >33 percent volume increase) occurs in 15 to 38 percent of patients over the first 24 hours [1-5]. The frequency of later hematoma expansion is less common; studies have reported that enlargement of ICH between 24 hours and two weeks occurs in less than 5 percent, probably closer to 1 to 2 percent, of patients [1,6-8]. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Hemorrhage enlargement'.)

Risk factors for hematoma expansion include antithrombotic therapy, sustained elevated blood pressure, large hematoma size, and evidence of contrast extravasation on initial CT imaging (“spot sign”). (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Hemorrhage enlargement'.)

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Literature review current through: Oct 2017. | This topic last updated: Apr 01, 2014.
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