ROMANIAN JOURNAL OF NEUROLOGY – VOLUME XI, NO. 1, 2012 13 REVIEWS ORAL ANTICOAGULATION RELATED INTRACEREBRAL HEMORRHAGE: MORE QUESTIONS THAN ANSWERS Elena Terecoasa 1 , Cristina Tiu 1 , Nuria Huertas 2 , Maria Alonso de Leciñana 3 1 Neurology Department, Emergency University Hospital, Bucharest, Romania 2 Neurology Department, Severo Ochoa University Hospital, Madrid, Spain 3 Neurology Department, Ramon y Cajal University Hospital, Madrid, Spain Author for correspondence: Elena Terecoasa, Neurology Department, Emergency University Hospital, Splaiul Independentei, No. 169, Bucharest, Romania e-mail: oana_ter@yahoo.com ABSTRACT Intracranial hemorrhage (ICH) is the most feared and devastating complication of oral anticoagulant therapy. When an ICH occurs, the patient’s situation hinges on the balance between how great is the embolic risk while not receiv- ing anticoagulants, and how big is the threat of the hemorrhage if the anticoagulant effect is not reversed prompt- ly. Although several studies which compared the use of different reversal agents failed to demonstrate any im- provement in prognosis and survival, at the present moment the consensus seem to be that anticoagulation should be rapidly reversed after an ICH. The second question to be answered is whether and when should be oral antico- agulation treatment restarted. Although the risk of thromboembolism in patients off anticoagulation seems to be higher than the risk of ICH recurrence, there is a marked paucity of prospective large studies on the real risk of ICH recurrence when OAC is resumed, paucity that probably emphasizes the ethical challenge of prescribing patients a medication to which they have an apparent contraindication. The little evidence available suggests that the opti- mal time for resumption is between 10 days and 30 weeks. Key words: intracerebral hemorrhage, oral anticoagulation, re-bleeding, atrial fibrillation, reversal of anticoagulation, resumption of anticoagulation Intracranial hemorrhage (ICH) is the most feared and devastating complication of anticoagulant treatment, leading to death or disability in two thirds of cases (1). Vitamin K antagonists (VKA, warfarin and acenocumarol) have long been the mainstay of an- ticoagulation therapy in atrial fibrillation. A strenu- ous effort has been made for many years in order to develop new oral anticoagulants as effective as VKA but with a superior pharmacological profile. For the moment there are two directions of research: the direct inhibitors of thrombin and the Xa factor antagonists. Unlike VKA, dietary restrictions and frequent blood sampling to monitor the degree of anticoagulation are unnecessary with the currently available new agents. The sole representative of the former category is dabigatran etexilate, which was recently included in both the ESC and AHA/ACC Guidelines for the management of atrial fibrillation as a result of the RE-LY trial (2). Dabigatran can be administrated either 110 mg twice a day or 150 mg twice a day, the lower dose being non-inferior to warfarin but having fewer hemorrhagic complications whereas the higher dose is superior in terms of thrombopro- phylaxis with the cost of a slightly higher incidence of bleeding, but not exceeding warfarin bleeding rate. The category of factor Xa antagonists is repre- sented at the moment by two drugs: rivaroxaban and apixaban, both of them being in Phase III of development. In the double-blind randomized ROCKET-AF trial (3), based on a population of over 14,000 patients with atrial fibrillation, rivar- oxaban (20 mg once a day) was non-inferior to warfarin in terms of stroke and non-central nervous system embolism prevention and had a lower rate of ICH but a higher risk of gastrointestinal bleed- ings. At the end of last year rivaroxaban was ap-