Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine

Abstract

Background: The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes.

Methods: The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated.

Results: Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage.

Conclusions: This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

Keywords: Activated prothrombin complex concentrates; Alteplase; Anticoagulant; Antidote; Antiplatelet; Antithrombotic; Apixaban; Aspirin; Clopidogrel; Coumadin; Cryoprecipitate; DDAVP; DTI; Dabigatran; Desmopressin; Direct thrombin inhibitor; Edoxaban; FEIBA; FFP; Factor Xa inhibitor; Fondaparinux; Fresh frozen plasma; GRADE criteria; Guideline; Heparin; Heparinoid; ICH; Intracerebral hemorrhage; Intracranial hemorrhage; Intraparenchymal hemorrhage; Low-molecular weight heparin; PCC; Pentasaccharide; Plasminogen activator; Platelets; Protamine; Prothrombin complex concentrates; Recombinant factor VIIa; Reversal; Rivaroxaban; SAH; SDH; Subarachnoid hemorrhage; Subdural hematoma; TPA; Thrombolytic; VKA; Vitamin K antagonist; Warfarin; aPCC; rFVIIa; rtPA.