Antiplatelet Therapy in Primary Spontaneous and Oral Anticoagulation–Associated Intracerebral Hemorrhage

Sprügel, Maximilian I.; Kuramatsu, Joji B.; Gerner, Stefan T.; Sembill, Jochen A.; Beuscher, Vanessa D.; Hagen, Manuel; Roeder, Sebastian S; Lücking, Hannes; Struffert, Tobias; Dörfler, Arnd; Schwab, Stefan; Huttner, Hagen B.

doi:10.1161/strokeaha.118.021614

Cited by 43 publications

(50 citation statements)

References 41 publications

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“…We differentiated primary spontaneous ICH in the absence of therapeutic anticoagulation (non‐OAC‐ICH) from ICH related to oral anticoagulants. OAC‐ICH was defined as either ICH on effective treatment with vitamin‐K‐antagonists (VKA) (INR > 1.5 on hospital admission) or ICH on known treatment with non‐vitamin‐K‐antagonist oral anticoagulant (NOAC) at symptom onset . We defined early care limitations as care limitation employed during first 24 h after hospital admission …”

Section: Methodsmentioning

confidence: 99%

“…OAC-ICH was defined as either ICH on effective treatment with vitamin-K-antagonists (VKA) (INR > 1.5 on hospital admission) or ICH on known treatment with non-vitamin-K-antagonist oral anticoagulant (NOAC) at symptom onset. 3,17,21,22 We defined early care limitations as care limitation employed during first 24 h after hospital admission. 23 Imaging Imaging data were analyzed by neuroradiologist blinded to clinical data.…”

Section: Data Acquisitionmentioning

confidence: 99%

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Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage

Sembill¹,

Kuramatsu²,

Gerner³

et al. 2020

Ann Clin Transl Neurol

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Objective Hematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobar ICH. Methods Pooled analysis of individual patient data between January 2006 and December 2015 from a German‐wide cohort study (RETRACE, I + II) investigating ICH related to oral anticoagulants (OAC) at 22 participating centers, and from one single‐center registry (UKER‐ICH) investigating non‐OAC‐ICH patients. Altogether, 1954 supratentorial ICH patients were eligible for outcome analyses, which were separately conducted or controlled for OAC, that is, vitamin‐K‐antagonists (VKA, n = 1186) and non‐vitamin‐K‐antagonist‐oral‐anticoagulants (NOAC, n = 107). Confounding was addressed using propensity score matching, cox regression modeling and multivariate modeling. Main outcomes were occurrence, extent, and timing of HE (>33%/>6 mL) and its association with 3‐month functional outcome. Results Occurrence of HE was not different after deep versus lobar ICH in patients with non‐OAC‐ICH (39/356 [11.0%] vs. 36/305 [11.8%], P = 0.73), VKA‐ICH (249/681 [36.6%] vs. 183/505 [36.2%], P = 0.91), and NOAC‐ICH (21/69 [30.4%] vs. 12/38 [31.6%], P = 0.90). HE extent did not differ after non‐OAC‐ICH (deep:+59% [40–122] vs. lobar:+74% [37–124], P = 0.65), but both patients with VKA‐ICH and NOAC‐ICH showed greater HE extent after deep ICH [VKA‐ICH, deep: +94% [54–199] vs. lobar: +56% [35–116], P < 0.001; NOAC‐ICH, deep: +74% [56–123] vs. lobar: +40% [21–49], P = 0.001). Deep compared to lobar ICH patients had higher HE hazard during first 13.5 h after onset (Hazard ratio [HR]: 1.85 [1.03–3.31], P = 0.04), followed by lower hazard (13.5–26.5 h, HR: 0.46 [0.23–0.89], P = 0.02), and equal hazard thereafter (HR: 0.96 [0.56–1.65], P = 0.89). Odds ratio for unfavorable outcome was higher after HE in deep (4.31 [2.71–6.86], P < 0.001) versus lobar ICH (2.82 [1.71–4.66], P < 0.001), and only significant after small‐medium (1st volume‐quarter, deep: 3.09 [1.52–6.29], P < 0.01; lobar: 3.86 [1.35–11.04], P = 0.01) as opposed to large‐sized ICH (4th volume‐quarter, deep: 1.09 [0.13–9.20], P = 0.94; lobar: 2.24 [0.72–7.04], P = 0.17). Interpretation HE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC‐ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small–medium compared to large‐sized bleedings.

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Section: Methodsmentioning

confidence: 99%

Section: Data Acquisitionmentioning

confidence: 99%

Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage

Sembill¹,

Kuramatsu²,

Gerner³

et al. 2020

Ann Clin Transl Neurol

Self Cite

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show abstract

“…Detailed information and methods of the multicenter RE-TRACE program (part 1 recruited patients from January 1, 2006, until December 31, 2010 [NCT01829581] and part 2 from January 1, 2011, until December 31, 2015 [NCT03093233]) have been published previously [3,[12][13][14][15].…”

Section: Study Participantsmentioning

confidence: 99%

“…1 . Off-hours VKA-ICH patients showed a significant higher National Institutes of Health Stroke Scale (NIHSS), (13 [6-21] vs. 10 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]; p < 0.01), a reduced Glasgow Coma Scale-Score (13 [10][11][12][13][14][15] vs. 14 [11][12][13][14][15]; p = 0.01), and a higher rate of intraventricular hemorrhage (447 [44.5%] vs. 108 [38.7%], p < 0.05) compared to on-hour VKA patients (Table 1). There was no difference regarding the time from symptom onset to hospital admission between on-and offhour VKA patients (98 min [60-266 min] vs. 101 min [60-260 min]; p = 0.97).…”

Section: Off-hour Admission and Baseline Characteristics For Vka-and mentioning

confidence: 99%

Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

et al. 2020

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Background: Prevention of hematoma enlargement in oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) focuses on blood pressure (BP) reduction and OAC reversal. We investigated whether treatment efficiency and clinical outcomes differ between OAC-ICH patients admitted outside versus during regular working hours. Methods: Based on pooled data of multicenter cohort studies, we grouped OAC-ICH patients (vitamin K antagonist [VKA], nonvitamin K oral anticoagulant [NOAC]) according to on-vs. offhour admission. Primary outcome was the functional outcome using the modified Rankin scale (mRS) dichotomized into favorable (mRS 0-3) and unfavorable (mRS 4-6) and mortality at 3 months. Secondary outcome measures included the occurrence of hematoma enlargement, the proportions of patients with systolic BP <140 mm Hg and with anticoagulation treatment achieving international normalized ratio (INR) levels <1.3 at 4 h. Propensity score matching (PSM) was performed to account for imbalances in baseline characteristics. Results: The study population consisted of 76/126 NOAC-ICH patients and 1,005/1,470 VKA patients presenting during off-hours. Functional outcome and mortality rates were not significantly different among PSM patients with VKA-ICH and NOAC-ICH during on-vs. off-hours (mRS 4-6 VKA-ICH: on-hour: 239/357 [66.9%] vs. 253/363 [69.7%] off-hour; p = 0.43; NOAC-ICH: on-hour 26/42 [61.9%] vs. offhour: 37/57 [64.9%]; p = 0.76; mRS 6 VKA-ICH: on-hour: 127/357 [35.6%] vs. off-hour: 148/363 [40.8%]; p = 0.15; NOAC-ICH: on-hour 17/42 [40.5%] vs. off-hour: 16/57 [28.1%]; p = 0.20). There were no differences detectable regarding the secondary outcome measures (i.e., hematoma enlargement, the proportion of patients who achieved systolic BP levels <140 mm Hg at 4 h as well as anticoagulation treatment achieving INR levels < 1.3 at 4 h) in OAC patients. Conclusion:Our study implies that BP reduction and anticoagulation reversal management are well established and associated with similar rates of hematoma enlargement and clinical outcomes in on-vs. off-hour admitted OAC-ICH patients.

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“…It has been previously shown that the mortality and neurologic outcome were worse for anticoagulant associated ICH. This could be due to larger haemorrhage volumes 21,22 , higher risk of hematoma expansion 4 , and higher comorbidities among anticoagulated patients 23 .…”

Section: Impact Of Anticoagulation Therapymentioning

confidence: 99%

Previous Antithrombotic Therapy, Particularly Anticoagulant, Is Associated with Unfavorable Outcomes in Patients with Primary Spontaneous Intracerebral Hemorrhage Receiving Craniotomy: A Nationwide Population-Based Cohort Study

Liu

Chen

et al. 2019

World Neurosurgery

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Objective The impact of antithrombotic agents on primary intracerebral hemorrhage (ICH) patients remains controversial, especially with patients that require emergent craniotomy. This study was to evaluate clinical outcomes in operated ICH patients with and without prior antithrombotic agents. Methods This is a retrospective cohort study. Between January 2001 to December 2013, all ICH patients that received emergent craniotomy and is present in Taiwan's National Health Insurance Research Database were screened, and divided into prior antiplatelet therapy, anticoagulant therapy and non-antithrombotic therapy according to patient's healthcare claims data within 3 months of index admission. The primary endpoints included in-hospital mortality and complication, and short-term outcome. Results Of 18,872 eligible patients, 16,251 (87.1%) patients did not receive any antithrombotic therapy, 2,267 patients had antiplatelet therapy and 354 patients had anticoagulation therapy. After propensity score matching, significantly higher amount of blood transfusion and number of craniectomy was identified in the patients with prior antithrombotic treatment compared with non-antithrombotic therapy. In comparison with the non-antithrombotic treatment cohort, patients under prior anticoagulant treatment had significantly higher in-hospital mortality rate (Odds ratio, 2.12; 95% confidence interval, 1.45-3.10). Furthermore, during the 6-month follow-up period, prior anticoagulant therapy was independently associated with a greater risk of all-cause mortality rates (P = 0.001). Interestingly, the in-hospital and 6-month all-cause mortality of patients with prior antiplatelet treatment was not significantly different to patients with non-antithrombotic treatment. Conclusion These findings suggested an increased risk of in-hospital mortality and poor short-term outcome among operated ICH patients with prior antithrombotic therapy, particularly anticoagulant therapy, but not with antiplatelet therapy. .

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Antiplatelet Therapy in Primary Spontaneous and Oral Anticoagulation–Associated Intracerebral Hemorrhage

Cited by 43 publications

References 41 publications

Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage

Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage

Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

Previous Antithrombotic Therapy, Particularly Anticoagulant, Is Associated with Unfavorable Outcomes in Patients with Primary Spontaneous Intracerebral Hemorrhage Receiving Craniotomy: A Nationwide Population-Based Cohort Study

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