Restarting Anticoagulation After Intracranial Hemorrhage Following Thrombolysis

Immediate Management

Immediately discontinue all anticoagulation and reverse the systemic fibrinolytic state created by thrombolytic therapy in patients with intracranial hemorrhage, according to the American Heart Association, as stated in Circulation 1, 2
Administer 6-8 units of platelets and cryoprecipitate to rapidly correct the coagulopathy induced by tPA, as recommended by the American Heart Association, in Circulation 1, 2
The prognosis for ICH after thrombolysis is particularly poor, with hemorrhages tending to be massive, multifocal, and associated with 30-day mortality rates exceeding 60%, as reported in Circulation 1, 2

Mechanical heart valves represent the highest risk category for thromboembolism, and warfarin may be restarted at 7-10 days after intracranial hemorrhage following thrombolysis, but only after careful risk-benefit assessment and confirmation of hemorrhage stability on neuroimaging, as stated in Circulation 1
Atrial fibrillation without prior stroke represents comparatively lower risk, and antiplatelet agents may be a better overall choice than warfarin, particularly in elderly patients with lobar ICH who have higher risk of cerebral amyloid angiopathy, as recommended by the American Heart Association, in Circulation 1, 2

Lobar ICH poses the greatest risk of recurrence when anticoagulation is reinstituted, likely due to underlying cerebral amyloid angiopathy, as reported in Stroke 3
A decision analysis study specifically recommended against restarting anticoagulation in patients with lobar ICH and atrial fibrillation, as stated in Stroke 3
Microbleeds on gradient echo MRI predict increased rebleeding risk and should prompt extreme caution or avoidance of anticoagulation restart, as reported in Stroke 3

For patients without lobar hemorrhage or high-risk features, anticoagulation can be restarted at 7-10 days after intracranial hemorrhage following thrombolysis, but only after careful risk-benefit assessment and confirmation of hemorrhage stability on neuroimaging, as stated in Circulation 1
Obtain repeat brain imaging before restart to confirm hemorrhage stability, as recommended by the American Heart Association, in Praxis Medical Insights: Practical Summaries of Clinical Guidelines 4

When anticoagulation is restarted, consider using intravenous heparin or LMWH initially rather than immediately restarting oral warfarin, as recommended by the American Heart Association, in Stroke 3
Heparin can be easily titrated, discontinued, and rapidly reversed with protamine sulfate if rebleeding occurs, as reported in Stroke 3
Target partial thromboplastin time 1.5-2.0 times normal, as recommended by the American Heart Association, in Stroke 3

Do not restart anticoagulation without repeat neuroimaging to confirm hemorrhage stability, as recommended by the American Heart Association, in Praxis Medical Insights: Practical Summaries of Clinical Guidelines 4
Do not use bridging therapy with heparin when starting NOACs, as this increases bleeding risk without benefit, as reported in the European Heart Journal 5
Do not restart anticoagulation in lobar ICH patients unless thromboembolism risk is extraordinarily high and alternative strategies have been exhausted, as stated in Stroke 3, 1