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The changing landscape of anticoagulant-related intracerebral hemorrhage

Hailed as a milestone in the management of patients with nonvalvular atrial fibrillation, new oral anticoagulants (NOACs) demonstrated comparable efficacy and similar or improved safety to vitamin K antagonists (VKAs) in randomized clinical trials.1 Their ensuing approvals by central regulatory agencies provoked reservations and caution by many in the medical community. Despite the consistent observation of a lower incidence of intracerebral hemorrhage (ICH) among users of various NOACs,1 the unexplored questions regarding the natural course and prognosis of NOAC-associated ICH, combined with an absence of specific treatment and management options during the initial phases of marketing, heightened the concern related to the safety of these agents. However, a closer look into the trial data was suggestive of similar mortality rates among patients experiencing ICH while using VKAs or NOACs.2–4 Real-world data originating from small single-center studies5,6 and administrative databases7 also showed no sign of excess mortality in NOAC-related ICH. Moreover, hematoma volume, the imaging marker most closely associated with clinical outcome, was smaller in those treated with NOACs, and hence suggested a more favorable profile compared to VKA users.7,8