Intracranial Hemorrhage Risk in the Era of Antithrombotic Therapies for Ischemic Stroke

Intracranial hemorrhage (ICH) is the most feared complication of antithrombotic medication use for the treatment and prevention of ischemic stroke. The risk of ICH while on blood thinners varies not only among different types of antithrombotics but also for the same agent used in different patient populations. Individual patients have different susceptibilities to ICH mostly due to the presence or absence of bleeding-prone cerebral pathologies such as cerebral amyloid angiopathy or hypertensive small vessel disease. The recent development and FDA approval of novel anticoagulants may lead to increased safety when compared to previously used medications, and the emergence of nonpharmacologic approaches may obviate the need for long-term anticoagulant strategies in certain clinical situations, such as left atrial appendage closure for stroke prevention in atrial fibrillation. As such, blanket recommendations for antithrombotic choice cannot be justified. Good practices in vascular neurology dictate combining all available data in order to choose the treatment that has the best risk-benefit ratio for each individual patient.