Between Scylla and Charybdis Antithrombotic and hemostatic therapy in intracerebral hemorrhage

Patients with spontaneous intracerebral hemorrhage (ICH) while taking antithrombotic therapy have relatively larger hematomas and more significant hematoma expansion, leading to poorer clinical outcome when compared to ICH patients without antithrombotic therapy. Treatment is therefore aimed at improving hemostasis by use of hemostatic (reversal) therapies in the hopes of reducing or preventing hematoma expansion. Hemostatic therapies however, are not without potential (thrombotic) risk. This thesis describes the challenge to sail between Scylla and Charybdis; between risk of hematoma expansion due to antithrombotic therapy and potential complications of hemostatic therapy.
We describe clinical outcome after ICH according to concomitant antithrombotic therapy use and explore evidence for hemostatic therapies in the literature. Then outcome after vitamin K antagonist-associated ICH according to reversal therapy is described in sever ICH as well as clinical practice and timing of reversal therapy in the Netherland. Finally, we focus on antiplatelet therapy (AP)-associated ICH and investigate the effect of platelet transfusion on clinical outcome of patients in a randomized controlled trial.