Abstract

This mini-review examines the management of spontaneous intracerebral haemorrhage (ICH) in patients using anticoagulant and antiplatelet medication. Atrial Fibrillation (AF), a significant risk factor for stroke, is often treated with anticoagulants to prevent cardioembolic events. However, ICH is a serious consequence of anticoagulation therapy, and managing patients who experience this “Black Swan” event is complex. While Vitamin K Antagonists (VKAs) like warfarin increase both the risk and severity of ICH, Direct Oral Anti-Coagulants (DOACs) offer a safer alternative with a lower mortality rate. We explore the pathophysiology of ICH, noting that anticoagulants disrupt the normal hemostatic process, potentially leading to excessive bleeding and hematoma expansion. This is particularly concerning as hematoma enlargement is associated with a poor prognosis. We examine the challenges of managing ICH in patients on anticoagulants, addressing aspects such as coagulation monitoring, reversal agents, and the decision to re-initiate anticoagulation therapy. Balancing the risk of recurrent ICH with the need to prevent thromboembolic events is a delicate process. There is need for more robust clinical data from prospective randomized trials to guide optimal management strategies for patients with AF who experience ICH, particularly regarding the timing and safety of resuming anticoagulation therapy.