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anticoagulant_related_intracerebral_hemorrhage_outcome

Anticoagulant Related Intracerebral Hemorrhage Outcome

Randomized trials in patients with atrial fibrillation (AF) show that direct non vitamin K oral anticoagulants (NOACs) have about half the incidence of intracerebral hemorrhage (ICH) compared to VKA but with a similar efficacy in preventing ischemic stroke 1).

In a international collaborative multicenter pooled analysis, baseline ICH volume, hematoma expansion, 90-day mortality, and functional outcome were similar following NOAC-ICH and VKA-ICH 2).


The aim of a study was to prospectively validate prior findings of smaller hematoma volume and lesser neurological deficit in Non vitamin K oral anticoagulant (NOAC) compared with Vitamin K antagonist (VKA)-related intracerebral hemorrhage (ICH).

It was a prospective 12-month observational study in 15 tertiary stroke centers in the United States, Europe, and Asia. Consecutive patients with premorbid modified Rankin Scale score of <2 with acute nontraumatic anticoagulant-related ICH divided into 2 groups according to the type of anticoagulant: NOAC versus VKA.

They recorded baseline ICH volume, significant hematoma expansion (absolute [12.5 mL] or relative [>33%] increase), neurological severity measured by National Institutes of Health Stroke Scale score, 90-day mortality, and functional status (modified Rankin Scale score).

The cohort comprised 196 patients, 62 NOAC related (mean age, 75.0±11.4 years; 54.8% men) and 134 VKA related (mean age, 72.3±10.5; 73.1% men). There were no differences in vascular comorbidities, antiplatelet, and statin use; NOAC-related ICH patients had lower median baseline hematoma volume (13.8 [2.5-37.6] versus 19.5 [6.6-52.0] mL; P=0.026) and were less likely to have severe neurological deficits (National Institutes of Health Stroke Scale score of >10 points) on admission (37% versus 55.3%, P=0.025). VKA-ICH were more likely to have significant hematoma expansion (37.4% versus 17%, P=0.008). NOAC pretreatment was independently associated with smaller baseline hematoma volume (standardized linear regression coefficient:-0.415 [95% CI, -0.780 to -0.051]) resulting in lower likelihood of severe neurological deficit (odds ratio, 0.44; 95% CI, 0.22-0.85) in multivariable-adjusted models.

Patients with NOAC-related ICH have smaller baseline hematoma volumes and lower odds of severe neurological deficit compared with VKA-related ICH. These findings are important for practicing clinicians making anticoagulation choices 3).


Serotonin-modulating antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) are frequently used in combination with warfarin, but it is unclear whether this combination of drugs influences outcome after primary intracerebral hemorrhage (PICH).

Concurrent use of warfarin and a serotonin-modulating antidepressant, relative to warfarin alone, seemed to increase the case fatality rate for PICH. This finding should be taken into account if hematoma evacuation is planned 4).

Whether intracerebral hemorrhage (ICH) survivors should restart antithrombotic drugs is unknown.

1)
Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014 Mar 15;383(9921):955-62. doi: 10.1016/S0140-6736(13)62343-0. Epub 2013 Dec 4. PubMed PMID: 24315724.
2)
Wilson D, Seiffge DJ, Traenka C, Basir G, Purrucker JC, Rizos T, Sobowale OA, Sallinen H, Yeh SJ, Wu TY, Ferrigno M, Houben R, Schreuder FHBM, Perry LA, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Ambler G, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Werring DJ; And the CROMIS-2 collaborators. Outcome of intracerebral hemorrhage associated with different oral anticoagulants. Neurology. 2017 May 2;88(18):1693-1700. doi: 10.1212/WNL.0000000000003886. Epub 2017 Apr 5. Erratum in: Neurology. 2018 Jun 5;90(23):1084. PubMed PMID: 28381513; PubMed Central PMCID: PMC5409844.
3)
Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Sharaf A, Chang J, Karapanayiotides T, Kargiotis O, Pappa A, Mai J, Pandhi A, Schroeder C, Tsantes A, Mehta C, Kerro A, Khan A, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Clinical Outcomes and Neuroimaging Profiles in Nondisabled Patients With Anticoagulant-Related Intracerebral Hemorrhage. Stroke. 2018 Oct;49(10):2309-2316. doi: 10.1161/STROKEAHA.118.021979. PubMed PMID: 30355114.
4)
Löppönen P, Tetri S, Juvela S, Huhtakangas J, Saloheimo P, Bode MK, Hillbom M.Association between warfarin combined with serotonin-modulating antidepressants and increased case fatality in primary intracerebral hemorrhage: a population-based study. J Neurosurg. 2014 Feb 7. [Epub ahead of print] PubMed PMID: 24506245.
anticoagulant_related_intracerebral_hemorrhage_outcome.txt · Last modified: 2018/11/21 21:23 by administrador