One in Three ICH Patients on Antithrombotics Lack Clinical Indication

A retrospective study finds 30.4% of patients with intracranial hemorrhage were taking unindicated anticoagulants or antiplatelets.

For Doctors in a Hurry

Clinicians frequently struggle to determine the appropriateness of anticoagulant and antiplatelet therapy in patients presenting with intracranial hemorrhage.
The researchers retrospectively reviewed 424 patients diagnosed with intracranial hemorrhage at a tertiary trauma hospital between 2020 and 2022.
Data revealed that 30.4 percent of patients were taking these medications without a clear indication according to current clinical guidelines.
The authors concluded that improper clinical indication is the primary driver of inappropriate medication use in this patient population.
Physicians should prioritize auditing aspirin and dual antiplatelet therapy to reduce unnecessary bleeding risks in their patients.

The Clinical Tension Between Thromboembolic Prevention and Iatrogenic Hemorrhage

Managing the delicate balance between preventing occlusive vascular events and minimizing the risk of iatrogenic intracranial hemorrhage remains a daily challenge for clinicians [1]. While antiplatelet agents and oral anticoagulants are essential for reducing the risk of ischemic stroke and systemic embolism, particularly in patients with atrial fibrillation, their use is inherently associated with an increased risk of life-threatening bleeding [2, 3]. Current clinical guidelines offer a framework for these therapies, yet the decision to initiate or continue treatment often involves navigating heterogeneous recommendations and complex patient-specific risk profiles [4, 3]. The clinical consequences of these decisions are profound, as intracranial hemorrhage carries high rates of morbidity and mortality regardless of the original treatment indication [4]. A new retrospective analysis now examines the frequency with which patients presenting with acute brain bleeds were taking these high-risk medications outside of established clinical indications.

Retrospective Analysis of Premorbid Medication Use

To evaluate the prevalence of unindicated medication use, researchers conducted a retrospective review of all intracranial hemorrhage diagnoses at a single tertiary trauma hospital. The study period spanned three years, from 2020 to 2022, providing a comprehensive dataset of patients presenting with acute neurological injury. The authors collected detailed clinical information for each case, including patient demographics, specific hemorrhage characteristics, hospital length of stay, and mortality data. This methodology allowed for a rigorous comparison between patients receiving appropriate therapy and those taking medications outside of established clinical guidelines, which is essential for identifying systemic prescribing errors that lead to avoidable adverse events. A central focus of the study was the impact of medications taken immediately prior to the bleeding event. The researchers defined premorbid anticoagulant or antiplatelet use as any documented use occurring within 7 days before the intracranial hemorrhage diagnosis. This specific timeframe was selected to ensure that the pharmacological effects of the drugs, such as the irreversible inhibition of cyclooxygenase-1 by aspirin or the competitive inhibition of vitamin K epoxide reductase by warfarin, were relevant to the clinical presentation. Out of a total of 2662 intracranial hemorrhage diagnoses identified during the study period, 424 patients (15.9%) met the inclusion criteria for premorbid anticoagulant or antiplatelet use. This cohort of 424 patients served as the primary group for the subsequent analysis of medication appropriateness.

Quantifying Inappropriate Antithrombotic Therapy

To evaluate the clinical necessity of antithrombotic regimens, the researchers determined the appropriateness of medication use by referencing all relevant clinical guidelines, including established standards for stroke prevention, cardiology, and hematology. This rigorous assessment revealed that anticoagulant or antiplatelet use was deemed inappropriate in 129 of the 424 encounters, representing 30.4% of the study population. This finding indicates that nearly one in three patients who presented with an intracranial hemorrhage while on these medications was receiving therapy that did not align with current evidence-based recommendations. The analysis further identified the specific reasons for these deviations from standard care. Improper indication was the leading cause for inappropriate use, accounting for 58% of the 129 cases where therapy was deemed unindicated. Overall, more than 30% of patients taking anticoagulants or antiplatelets before their intracranial hemorrhage were doing so for indications falling outside current clinical guidelines. These data suggest that a substantial portion of the iatrogenic risk associated with these medications may be avoidable through stricter adherence to established prescribing protocols, particularly regarding primary prevention and long-term dual antiplatelet therapy. For the practicing clinician, these figures highlight a significant gap between guideline-directed medical therapy and real-world prescribing, where the perceived benefit of thrombosis prevention may be overvalued against the tangible risk of catastrophic bleeding.

Identifying High-Risk Prescribing Patterns

The researchers identified specific prescribing patterns that frequently lacked a clinical indication, placing patients at unnecessary risk for intracranial hemorrhage. A primary area of concern involved the use of aspirin 81 mg for primary prevention, which refers to the use of antiplatelet medication to prevent a first cardiovascular event in patients without established vascular disease. Despite evolving clinical guidelines that have increasingly restricted the use of aspirin for primary prevention due to the elevated risk of major bleeding, this specific regimen remained a frequent factor in cases of unindicated antiplatelet use among the study population. Another high-risk pattern identified in the analysis was the use of dual antiplatelet therapy for secondary prevention, the practice of combining two antiplatelet agents, such as aspirin and a P2Y12 inhibitor, to prevent recurrent events in patients with known disease. While dual antiplatelet therapy is indicated for specific, time-limited durations following acute coronary syndromes or percutaneous interventions, its continuation beyond recommended windows often lacks clinical justification. The findings suggest that neurosurgical providers should be particularly vigilant when treating patients on these regimens, as they represent significant opportunities for medication reconciliation to reduce unnecessary hemorrhagic risk. Notably, the study found that the inappropriate use of these medications was not confined to any specific patient demographic or socioeconomic group. No significant differences based on age, sex, race, or insurance were found when comparing appropriate versus inappropriate anticoagulant or antiplatelet use (p-values not significant). This lack of demographic or socioeconomic predictors indicates that the challenge of unindicated prescribing is a widespread clinical issue that transcends patient background or healthcare access, necessitating a broad, systemic approach to guideline adherence across all patient populations.

Clinical Implications for Risk Mitigation

Intracranial hemorrhage is a known risk factor associated with the use of oral anticoagulants and antiplatelets, making the management of these agents a frequent problem for neurosurgeons and critical care physicians. The challenge is compounded by the fact that guidelines regarding the initiation and continuation of both oral anticoagulants and antiplatelets are heterogeneous and complex, often leading to clinical ambiguity. To evaluate the impact of these prescribing practices, the researchers retrospectively reviewed all intracranial hemorrhage diagnoses at a tertiary trauma hospital from 2020 to 2022. From a total of 2662 intracranial hemorrhage diagnoses, the study analyzed 424 patients (15.9%) who met inclusion criteria for premorbid medication use. The researchers collected comprehensive data including demographics, hemorrhage characteristics, length of stay, and mortality to assess the clinical severity and outcomes within this cohort. The finding that 30.4% of patients (129 encounters) were taking these medications inappropriately, with improper indication (58%) as the primary cause, necessitates a shift toward more rigorous medication reconciliation. Neurosurgical providers should be particularly vigilant in identifying patients taking aspirin 81 mg for primary prevention or dual antiplatelet therapy for secondary prevention, as these regimens were most likely to fall outside current clinical guidelines. Because these medications are frequently initiated by primary care or cardiovascular specialists, reducing the risk of iatrogenic hemorrhage requires active, interdisciplinary collaboration. By reconciling medications and ensuring that antithrombotic therapy is strictly indicated, clinicians can mitigate the unnecessary risk of life-threatening bleeding events in vulnerable patient populations.

Study Info

Inappropriate Use of Anticoagulants and Antiplatelets in Intracranial Hemorrhage Patients: A Retrospective Study From a Tertiary Referral Level 1 Trauma Center

Catherine Stewart Nichols, Emal Lesha, Prateek Konakalla, Kara A. Parikh, et al.

Journal Neurosurgery

Published April 22, 2026