Beyond Hemostasis: Integrated Anticoagulation Reversal, Hemodynamic Optimization, and Neurosurgical Decision-Making in Intracerebral Hemorrhage

Anticoagulant-associated intracerebral hemorrhage represents a life-threatening neurological emergency characterized by rapid hematoma expansion, secondary cerebral injury, and substantial risks of mortality and long-term functional disability. Its management requires coordinated therapeutic strategies addressing anticoagulant activity, systemic hemodynamics, and intracranial complications. This narrative review critically examines current international evidence regarding pharmacological reversal, blood pressure management, and neurosurgical intervention, incorporating perspectives relevant to Latin American healthcare systems. Twenty scientific publications, including randomized controlled trials, observational investigations, and clinical guidelines, were analyzed through a comparative qualitative approach. Evidence from the INCH trial demonstrated more rapid normalization of coagulation parameters with four-factor prothrombin complex concentrate than with fresh frozen plasma. ANNEXA-I reported greater hemostatic efficacy with andexanet alfa compared with usual care, although thrombotic complications were more frequent and functional benefits were not established. Findings from INTERACT2 and ATACH-II highlighted differences in clinical outcomes associated with intensive blood pressure reduction, whereas INTERACT3 demonstrated improved functional outcomes through coordinated management of physiological abnormalities. Neurosurgical evidence from MISTIE III and ENRICH revealed that the effectiveness of minimally invasive hematoma evacuation depends on procedural technique, anatomical characteristics, treatment timing, and patient selection. Across the reviewed studies, improvements in hemostatic or radiological parameters did not consistently translate into reduced mortality or sustained neurological recovery. The findings support an individualized, multidisciplinary approach integrating prompt anticoagulant reversal, controlled hemodynamic stabilization, continuous neurological assessment, and selective neurosurgical treatment. Further investigations are needed to establish optimal therapeutic sequencing, anticoagulant-specific surgical criteria, and implementation strategies adapted to resource-variable healthcare environments.