Day: August 25, 2026

Neurosurgery 99:354–363, 2026

Antithrombotic treatment complicates emergency surgery for spontaneous intracerebral hemorrhage even after pharmacological reversal. This study compares hematoma burden, evacuation efficacy and functional outcome according to prior antithrombotic medication. Patients receiving these drugs presented with larger hemorrhages and had more residual blood after microsurgery. The signal was particularly concerning for antiplatelet and combined antiplatelet–anticoagulant therapy. The results emphasize that laboratory correction does not necessarily eliminate the operative consequences of disturbed hemostasis.

Objective

To determine how common categories of antithrombotic therapy affect preoperative hematoma volume, microsurgical evacuation efficacy and 12-month functional outcome in supratentorial spontaneous intracerebral hemorrhage.

Methods

The authors retrospectively studied 232 consecutive patients who underwent microsurgical evacuation between 2008 and 2022. Patients receiving antiplatelets, vitamin K antagonists, direct oral anticoagulants or combined antiplatelet–anticoagulant therapy were compared with patients taking no antithrombotic drug. Imaging, emergency reversal and modified Rankin Scale outcome at 12 months were analyzed using multivariable regression.

Main results

The cohort included 53 patients receiving antiplatelets, 29 receiving vitamin K antagonists, 13 receiving direct oral anticoagulants and 17 receiving combined therapy. Every antithrombotic category was associated with a larger absolute preoperative hematoma; the largest adjusted difference occurred with combined therapy (14.9 mL; 95% CI 0.9–29.0).

Antiplatelet therapy was associated with a 1.4-fold greater relative postoperative hematoma volume (95% CI 0.9–2.1), and combined therapy with a 2.1-fold increase (95% CI 1.1–4.0). Unfavorable 12-month outcome (mRS ≥4) occurred in 73.5% and was associated with larger preoperative and relative postoperative hematoma volumes.

Interpretation

Prior antithrombotic therapy appears to influence both the initial hemorrhage and completeness of microsurgical evacuation. The association does not prove that a different reversal regimen would improve outcome, but it identifies persistent hemostatic risk—especially with antiplatelet exposure—that should inform operative planning and postoperative imaging.

Limitations

This retrospective study spans 14 years, during which reversal protocols and perioperative practice evolved. The treatment groups were small, particularly for direct oral anticoagulants and combined therapy. Confounding by age, comorbidity, hemorrhage severity and indication for antithrombotic treatment cannot be completely excluded.

Clinical takeaway

Do not regard emergency reversal as complete normalization of surgical bleeding risk. In patients previously taking antiplatelets or combined therapy, plan meticulous hemostasis, consider early postoperative imaging and maintain a low threshold for detecting clinically important residual or recurrent hematoma.