Table 4

Summary of recommendations

DilemmaRecommendations
Antithrombotic use after intracerebral haemorrhage

  • Use antiplatelets if there is a strong indication (eg, related to ischaemic hear disease, ischaemic stroke or TIA).

  • Whether to start or avoid OAC after ICH in patients with AF remains uncertain.

  • If restarting OAC, reinitiating with an NOAC at 7–8 weeks appears sensible.

  • The role of LAAO remains uncertain in ICH survivors with AF.

  • Recruitment to ongoing RCTs of OAC and LAAO is recommended.

Antithrombotic use in patients with CMBs

  • Use antiplatelets or OAC if indicated.

  • Use the MICON-ICH score to determine the risk of future intracranial bleeding.

  • Avoid OAC in patients with CMBs in the context of ICH and probable CAA.

  • Careful management of modifiable bleeding risk factors.

Antithrombotic use in patients with indications for antiplatelets and OAC

  • Use combination therapy in patients with recent ACS.

  • Avoid combination therapy in patients with coronary or peripheral artery disease without associated vascular events in the last 12 months.

  • Pay attention to modifiable bleeding risk factors if combination therapy used.

  • Consider early cessation of combination therapy in patients at high bleeding risk (eg, HASBLED >3).

  • Novel combination strategies (eg, low-dose NOAC and antiplatelet) should be investigated.

Timing of anticoagulation after AF-associated ischaemic stroke

  • Optimal timing remains to be determined for all degrees of stroke severity: offer enrolment to RCT if available.

  • If no RCT available, early anticoagulation (within 5 days) with an NOAC is probably safe in patients with minor stroke.

  • Delay anticoagulation by 5–14 days in patients with moderate-severe stroke.

Antithrombotic ‘failure’

  • Review medication dosing, compliance, and interactions.

  • Investigate for competing aetiology.

  • Consider short-term dual antiplatelet therapy in patients with recurrent non-cardioembolic stroke despite antiplatelets.

  • Switch of anticoagulant type in patients with AF does not appear to reduce recurrence risk.

‘Silent’ cerebral small vessel disease

  • Routine antiplatelet use not recommended for asymptomatic cerebral small vessel disease.

  • Consider antiplatelets in patients with asymptomatic territorial infarcts of likely atherosclerotic or atheroembolic cause.

  • ACS, acute coronary syndrome; AF, atrial fibrillation; CAA, cerebral amyloid angiopathy; CMB, cerebral microbleed; HASBLED, Hypertension, Abnormal renal/liver function, Stroke history, Bleeding, Labile international normalised ratio, Elderly, Drugs score; ICH, intracerebral haemorrhage; LAAO, left atrial appendage occlusion; MICON, Microbleeds International Collaborative Network; NOAC, non-vitamin K OAC; OAC, oral anticoagulant; RCT, randomised controlled trial; TIA, transient ischaemic attack.