Evidence against rapid reversal of antiplatelet medications in acute intracerebral hemorrhage

Volume of intracerebral hemorrhage (ICH) is the most important determinant of outcome after ICH.^1,2 In prospective studies, the volume of ICH increases by more than a third in 28–38% of patients with ICH during the first hours after onset and this growth is associated with neurologic deterioration.^1,3 Identification of factors that are related to the baseline volume of ICH and subsequent ICH growth can provide insights into the pathophysiology of ICH and can lead to potential therapies designed to limit or stop ICH growth.

The most consistently identified factor associated with ICH growth is the time from symptom onset to baseline CT imaging, which demonstrates the time-dependent nature of ICH growth that is limited in most patients to the first 3–4 hours.^1,3,4 Warfarin use is clearly associated with larger volumes of ICH on the baseline CT, subsequent ICH growth, and increased mortality.^5,6 The biologic underpinning for this association is straightforward and therapy to reverse the anticoagulant effect of warfarin is part of standard practice in patients with ICH.² Proposed trials of newer agents to more quickly reverse the …