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Meta-Analysis
. 2017 May 25;5(5):CD012144.
doi: 10.1002/14651858.CD012144.pub2.

Antithrombotic treatment after stroke due to intracerebral haemorrhage

Luke A Perry  1 , Eivind Berge  2 , Joshua Bowditch  1 , Elisabeth Forfang  2 , Ole Morten Rønning  3 , Graeme J Hankey  4 , Elmer Villanueva  5 , Rustam Al-Shahi Salman  6
Affiliations
Meta-Analysis

Antithrombotic treatment after stroke due to intracerebral haemorrhage

Luke A Perry et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of thromboembolism. Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of thromboembolism after ICH, but they may increase the risks of bleeding.

Objectives: To determine the overall effectiveness and safety of antithrombotic drugs for people with ICH.

Search methods: We searched the Cochrane Stroke Group Trials Register (24 March 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2017, Issue 3), MEDLINE Ovid (from 1948 to March 2017), Embase Ovid (from 1980 to March 2017), and online registries of clinical trials (8 March 2017). We also screened the reference lists of included trials for additional, potentially relevant studies.

Selection criteria: We selected all randomised controlled trials (RCTs) of any antithrombotic treatment after ICH.

Data collection and analysis: Three review authors independently extracted data. We converted categorical estimates of effect to the risk ratio (RR) or odds ratio (OR), as appropriate. We divided our analyses into short- and long-term treatment, and used fixed-effect modelling for meta-analyses. Three review authors independently assessed the included RCTs for risks of bias and we created a 'Summary of findings' table using GRADE.

Main results: We included two 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, with the exception of blinding of participants and personnel, which was not done. The included RCTs did not report our chosen primary outcome (a composite outcome of all serious vascular events including ischaemic stroke, myocardial infarction, other major ischaemic event, ICH, major extracerebral haemorrhage, and vascular death). Parenteral anticoagulation did not cause a statistically significant difference in case fatality (RR 1.25, 95% confidence interval (CI) 0.38 to 4.07 in one RCT involving 46 participants, low-quality evidence), ICH, or major extracerebral haemorrhage (no detected events in one RCT involving 75 participants, low-quality evidence), growth of ICH (RR 1.64, 95% CI 0.51 to 5.29 in two RCTs involving 121 participants, low-quality evidence), deep vein thrombosis (RR 0.99, 95% CI 0.49 to 1.96 in two RCTs involving 121 participants, low quality evidence), or major ischaemic events (RR 0.54, 95% CI 0.23 to 1.28 in two RCTs involving 121 participants, low quality evidence).

Authors' conclusions: 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.

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Conflict of interest statement

Luke A Perry: none known Eivind Berge: co‐ordinating investigator of the ongoing STATICH trial. Joshua Bowditch: none known Elisabeth Forfang: managing investigator of the ongoing STATICH trial. Ole Morten Rønning: none known Graeme J Hankey: in the past three years, GJH has received honoraria from AC Immune for chairing the data safety monitoring committee of two clinical trials of vaccines for Alzheimer’s disease, from Bayer for lecturing about stroke prevention in atrial fibrillation at sponsored scientific symposia, and from Medscape, Web MD for participating in a discussion about stroke prevention in atrial fibrillation for theheart.org. Elmer Villanueva: none known Rustam Al‐Shahi Salman: Chief investigator of the UK REstart or STop Antithrombotics Randomised Trial (RESTART, www.RESTARTtrial.org, ISRCTN71907627), which is funded by a special project grant from the British Heart Foundation.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.2
1.2. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 2 Death.
1.6
1.6. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 6 Other major ischaemic event.
1.7
1.7. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 7 Intracerebral haemorrhage.
1.8
1.8. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 8 Major extracerebral haemorrhage.
1.9
1.9. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 9 Growth of intracerebral haematoma.
1.10
1.10. Analysis
Comparison 1 Short‐term antithrombotic treatment, Outcome 10 Deep vein thrombosis.
See this image and copyright information in PMC

References

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Perry 2016
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