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Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage

A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine

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Abstract

Background

The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes.

Methods

The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated.

Results

Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage.

Conclusions

This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

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Acknowledgments

We would like to thank Zoe Oliver, MD and Frederick A. Zeiler, MD for their contributions to this document.

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Correspondence to Jennifer A. Frontera.

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Disclosures

D. Aisiku serves on the National Advisory Board for the Medicines Company, Dr. Alexandrov serves on the speakers bureau for Genentech. Dr. del Zoppo has received research funds from the NIH, Boehringer Ingelheim, and Novartis. He has served on advisory boards for Boehringer Ingelheim, Daiichi-Sankyo, and Novartis. Dr. Kumar has received support from Haemonetics. Dr. Stiefel serves as a consultant for Medtronic and Penumbra. The remaining authors have nothing to disclose.

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The Neurocritical Care Society and Society of Critical Care Medicine affirm the value of this guideline as an educational tool for clinicians.

Jennifer A. Frontera and John J. Lewin III are guideline co-chairs.

Jennifer A. Frontera and John J. Lewin III have contributed equally to the manuscript.

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Frontera, J.A., Lewin III, J.J., Rabinstein, A.A. et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage. Neurocrit Care 24, 6–46 (2016). https://doi.org/10.1007/s12028-015-0222-x

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