Amor Salah: 2026 NCS/SCCM Guidelines for Managing Antithrombotic-Associated ICH
Amor Salah, Consulting Associate at MetaQare IntelliHealth, shared a post on LinkedIn about a recent article by Meghan Caylor Vallejo et al, published in Springer Nature, adding:
“2026 NCS/SCCM Guideline Update on Antithrombotic-Associated ICH.
This focused guideline update from the Neurocritical Care Society (NCS) and Society of Critical Care Medicine (SCCM) provides evidence-based recommendations using GRADE methodology for managing acute antithrombotic-associated intracranial hemorrhage (ICH) in adult patients.
Key Recommendations:
1. Factor Xa Inhibitor Reversal:
The panel conditionally recommends 4-factor prothrombin complex concentrate (4F-PCC) over andexanet alfa for both spontaneous intraparenchymal hemorrhage (IPH) and traumatic ICH. Although andexanet alfa improves hemostatic efficacy, meta-analyses show no mortality or functional outcome benefits. Crucially, andexanet alfa increases thrombotic risk. Combining 4F-PCC and andexanet alfa is explicitly advised against.
2. Platelet Transfusion in Antiplatelet Use:
- Spontaneous IPH without Surgery: Suggests against platelet transfusion, as evidence shows no mortality benefit and potential functional harm.
- Spontaneous IPH with Surgery: Suggests platelet transfusion for patients on aspirin undergoing neurosurgical intervention.
- Traumatic ICH: Issues no recommendation due to very low certainty evidence.
3. Desmopressin (DDAVP):
The panel makes no recommendation regarding desmopressin in antiplatelet-associated ICH due to insufficient evidence of clinical efficacy.
4. Small Spontaneous IPH:
Makes no recommendation on reversing anticoagulant effects in small IPH (<5–10 mL) due to lack of direct evidence.
5. Viscoelastic Hemostatic Assays (VHAs):
Conditionally suggests VHA-guided (TEG/ROTEM) management in traumatic ICH when available, supported by potential mortality reduction.”
Title: Treatment of Antithrombotic-Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and the Society of Critical Care Medicine
Authors: Meghan Caylor Vallejo, Lori S. Kennedy, Bradley Dengler, Colleen Barthol, Emilie P. Belley-Cote, Joseph D. Burns, Veda K. Chau, Charlotte Cordonnier, Adam Cuker, Kimia Honarmand, Sherif Hanafy Mahmoud, M. Elizabeth Wilcox and Monisha A. Kumar
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