Intracerebral Hematoma Occurring During Warfarin Versus Non–Vitamin K Antagonist Oral Anticoagulant Therapy

Takahashi, Hidemi; Jimbo, Yasushi; Takano, Hiroki; Abe, Hiroshi; Sato, Masahito; Fujii, Yukihiko; Aizawa, Yoshifusa

doi:10.1016/j.amjcard.2016.04.034

Cited by 35 publications

(22 citation statements)

References 19 publications

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“…33 Indeed, several experimental and clinical studies have reported on the benefit of DOACs in ICH. 3,7,24,29,33 However, no such benefit was observed in patients with aSDH in our study, and preinjury DOAC therapy was even associated with an increased midline shift. Fleck et al reported that the concentrations of TF depended on the location from which the tissue was obtained.…”

Section: 1319contrasting

confidence: 45%

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Won

Dubinski

Bruder

et al. 2017

Neurosurgical Focus

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OBJECTIVEIsolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT—with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants—is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation.METHODSIn this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified.RESULTSOf 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1–2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R2 = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R2 = 0.466). OAT itself was not an independent predictor for worse outcome.CONCLUSIONSAn OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.

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Section: 1319contrasting

confidence: 45%

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Won

Dubinski

Bruder

et al. 2017

Neurosurgical Focus

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“…Therefore, in our study, it was noteworthy that in ICH-DOACs, the bleed was smaller, an intraventricular component was less frequent, and stroke-related mortality was lower than in ICH-VKAs (all differences statistically significant). In other studies [4,21,30], there was also a greater trend toward functional independence at 3 months, which in our study, as in a recent study in Portugal [22], did not reach statistical significance.…”

Section: Discussionsupporting

confidence: 45%

Epidemiology of Intracranial Hemorrhage Associated with Oral Anticoagulants in Spain: Trends in Anticoagulation Complications Registry – The TAC 2 Study

et al. 2018

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Objective: Patients receiving treatment with oral anticoagulants (OACs) are at risk of intracranial hemorrhage (ICH). In this study, we describe the epidemiological and clinical characteristics of patients receiving OACs who experience ICH and compare those receiving vitamin K antagonists (ICH-VKAs) with those receiving direct OACs (ICH-DOACs). Methods: We performed a national, multicenter, descriptive, observational, retrospective study of all adult patients receiving OACs who were admitted to the neurology department with ICH over a 1-year period. The study population was divided into 2 groups (ICH-VKAs and ICH-DOACs). Epidemiological, clinical, radiological, and therapy-related variables, as well as functional outcome, were compared at 3 months. A total of 366 cases were included (331 ICH-VKAs, 35 ICH- DOACs). Results: The crude annual incidence of OAC-induced ICH was 3.8 (95% CI, 2.78–3.41) per 100,000 inhabitants/year. The mean (± SD) age was greater for ICH-DOACs (81.5 ± 8.3 vs. 77.7 ± 8.3 years; p = 0.012). The median (IQR) volume of the hemorrhage was lower for ICH-DOACs (11 [30.8] vs. 25 [50.7] mL; p = 0.03). The functional independence rate at 3 months (modified Rankin Scale, mRS < 3) was similar in both groups, although stroke-related mortality was greater in ICH-VKAs (40 vs. 72.7%; p = 0.02). The most frequently indicated poststroke antithrombotic therapy was DOACs (38.7%). Conclusion: We found that the incidence of OAC-induced ICH was greater than in previous studies. Hemorrhage volume and mortality were lower in ICH-DOACs than in ICH-VKAs. After stroke, DOACs were the most frequently indicated antithrombotic treatment.

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“…In one study26 that compared only median mRS at discharge, there was no difference between NOAC-ICH versus VKA-ICH. In the other study which presented only mean mRS, NOAC-ICH showed a slightly better outcome at discharge compared with VKA-ICH in univariable analysis (mean mRS (SD): 3.2 (1.4) vs 4.5 (1.6), respectively) 19. In a posthoc sensitivity analysis of unfavourable outcome at discharge defined as mRS 3–6, pooled data from four studies14 17 20 25 (123 NOAC-ICH vs 577 VKA-ICH) demostrated no difference between the two groups (OR: 1.09; 95% CI 0.37 to 3.25, p=0.876, I2: 63.4%, forest plots not shown).…”

Section: Resultsmentioning

confidence: 72%

Outcome of intracerebral haemorrhage related to non-vitamin K antagonists oral anticoagulants versus vitamin K antagonists: a comprehensive systematic review and meta-analysis

Boulouis

Morotti

Pasi

et al. 2017

J Neurol Neurosurg Psychiatry

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Intracerebral Hematoma Occurring During Warfarin Versus Non–Vitamin K Antagonist Oral Anticoagulant Therapy

Cited by 35 publications

References 19 publications

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Epidemiology of Intracranial Hemorrhage Associated with Oral Anticoagulants in Spain: Trends in Anticoagulation Complications Registry – The TAC 2 Study

Outcome of intracerebral haemorrhage related to non-vitamin K antagonists oral anticoagulants versus vitamin K antagonists: a comprehensive systematic review and meta-analysis

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