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Background <p>Reversal treatment is used to counterbalance effects of oral anticoagulation in intracranial hemorrhages. Despite effects on reducing hematoma expansion, the impact on mortality remains uncertain. Our aim was to assess the effects of reversal treatment on mortality in various forms of oral anticoagulant-associated intracranial hemorrhage.</p> Methods <p>Systematic searches were performed in the electronic databases of PubMed, Embase, Scopus, and Web of Science from database inception to March 2025. We included studies that compared mortality between patients receiving reversal treatment vs. non-reversal in oral-anticoagulant-associated intracranial hemorrhages. Only studies with appropriate statistical controlling for significant confounding variables were included. Data extraction and synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data were summarized and pooled effect estimates were presented. Outcome was mortality, and primarily with a follow-up limited to 3&#xa0;months.</p> Results <p>A total of 8217 studies were screened; 8 were ultimately included, all observational, and including 8777 participants with documented reversal treatment. For the overall analysis, when all types of intracranial hemorrhage and all types of anticoagulants were included, reversal was associated with reduced mortality (RR 0.78 (95% CI 0.67–0.91); <i>p</i> = 0.002). This association was also seen in the subgroup analysis of 8639 participants with nontraumatic intracerebral hemorrhage on any oral anticoagulant (RR 0.77 (95% CI 0.64–0.94);<i> p</i> = 0.009), but not among the 3059 participants with intracerebral hemorrhage treated with only direct oral anticoagulants (RR 0.91 (95% CI 0.80–1.03); <i>p</i> = 0.15).</p> Conclusions <p>Current evidence for reduced mortality following anticoagulant reversal in intracranial hemorrhage is limited and primarily derived from observational studies. Although pooled data suggest a potential treatment benefit across various types of intracranial hemorrhages and anticoagulants, most hemorrhage subtypes remain insufficiently studied. Going forward, there is a critical need for randomized clinical trials and additional well-controlled observational studies to determine which patients truly benefit from reversal treatment.</p>

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Effect on Mortality of Anticoagulant Reversal in Acute Intracranial Hemorrhage: A Systematic Review and Meta-analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年7月20日

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  • Mattias Tallroth,
  • Linda Östlundh,
  • András Büki,
  • Yang Cao,
  • Mia von Euler,
  • Jakob O. Ström

摘要

Background

Reversal treatment is used to counterbalance effects of oral anticoagulation in intracranial hemorrhages. Despite effects on reducing hematoma expansion, the impact on mortality remains uncertain. Our aim was to assess the effects of reversal treatment on mortality in various forms of oral anticoagulant-associated intracranial hemorrhage.

Methods

Systematic searches were performed in the electronic databases of PubMed, Embase, Scopus, and Web of Science from database inception to March 2025. We included studies that compared mortality between patients receiving reversal treatment vs. non-reversal in oral-anticoagulant-associated intracranial hemorrhages. Only studies with appropriate statistical controlling for significant confounding variables were included. Data extraction and synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data were summarized and pooled effect estimates were presented. Outcome was mortality, and primarily with a follow-up limited to 3 months.

Results

A total of 8217 studies were screened; 8 were ultimately included, all observational, and including 8777 participants with documented reversal treatment. For the overall analysis, when all types of intracranial hemorrhage and all types of anticoagulants were included, reversal was associated with reduced mortality (RR 0.78 (95% CI 0.67–0.91); p = 0.002). This association was also seen in the subgroup analysis of 8639 participants with nontraumatic intracerebral hemorrhage on any oral anticoagulant (RR 0.77 (95% CI 0.64–0.94); p = 0.009), but not among the 3059 participants with intracerebral hemorrhage treated with only direct oral anticoagulants (RR 0.91 (95% CI 0.80–1.03); p = 0.15).

Conclusions

Current evidence for reduced mortality following anticoagulant reversal in intracranial hemorrhage is limited and primarily derived from observational studies. Although pooled data suggest a potential treatment benefit across various types of intracranial hemorrhages and anticoagulants, most hemorrhage subtypes remain insufficiently studied. Going forward, there is a critical need for randomized clinical trials and additional well-controlled observational studies to determine which patients truly benefit from reversal treatment.