Brain imaging with emergency neurological and neurosurgical consultation is required. Consideration can be given to the use of protamine, fresh frozen plasma, prothrom- bin complex concentrates, activated factor VII,555 and platelets as indicated. Resumption and timing of anticoagulant and/or antiplatelet therapy after ICH should be individualized and guided by neurosurgical consultation.556 9.7.2.2. Vascular Access Site Bleeding Vascular access site bleeding is the most common type of bleeding after STEMI, particularly after PCI. PCI trials have identified female sex, advanced age, renal insufficiency, ane- mia, IABP, use of GP IIb/IIIa antagonists, and low-molecu- lar-weight heparin within 48 hours of PCI as risk factors for femoral access site bleeding.557 Larger sheath size, postpro- cedural heparin use, higher activated clotting times, and late postprocedural sheath removal increases the risk of access site bleeding and should be avoided. Radial artery access may decrease bleeding complications and should be con- sidered whenever feasible,558 but procedural success with this technique is dependent on operator experience.559,560 Among patients with STEMI in the RIVAL (Radial Versus Femoral Access for Coronary Angiography and Interven- tion in Patients with Acute Coronary Syndromes) trial, radial artery access appeared to reduce the rate of the primary composite outcome (death, MI, stroke, non CABG-related Figure 4. Adjusted risk of nonfatal and fatal bleeding in patients treated with aspirin, clopidogrel, and/or vitamin K antagonists after first MI. Compared with aspirin alone, triple therapy is associated with a 3- to 4-fold increased risk of fatal and nonfa- tal bleeding. CI indicates confidence interval; HR, hazard ratio; and MI, myocardial infarction. Adapted with permission from S rensen et al.533 Table 13. 