Intracerebral Hemorrhage Formation Under Direct Oral Anticoagulants

Foerch, Christian; Lo, Eng H.; Leyen, Klaus van; Lauer, Arne; Schaefer, Jan Hendrik

doi:10.1161/strokeaha.118.023722

Cited by 12 publications

(9 citation statements)

References 54 publications

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“…Previous studies have described a larger hemorrhage volume and increased progression of bleed in patients on warfarin compared with those not on anticoagulation. 30,31 Because of the small number of patients undergoing intervention, we may not have been able to detect small differences in neurosurgical intervention among other groups.…”

Section: Discussionmentioning

confidence: 99%

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Grewal

Atzema

Austin

et al. 2021

CMAJ

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alls resulting in a head injury are common among older adults. 1,2 Advanced age and anticoagulation are thought to be associated with an increased risk of intracranial hemorrhage (ICH) after a head injury. [3][4][5] With the aging population and increasing use of anticoagulants, older patients on anticoagulation are commonly seen in the emergency department after a head injury. The Canadian CT Head Rule suggests that patients presenting to the emergency department with a minor head injury who are older than 65 years should undergo head imaging to rule out ICH. 6 This clinical decision tool did not include patients on anticoagulation; however, a clinical policy from the American College of Emergency Physician suggests computed tomography (CT) imaging for these patients. 7 Before 2010, warfarin, a vitamin K antagonist, was the oral anticoagulant used most commonly in North America. Since then, direct oral anticoagulants (DOACs) have been approved for various indications including treatment of venous thromboembolism, prevention of venous thromboembolism after arthroplasty, and stroke prophylaxis in patients with atrial fibrillation. Unlike warfarin, DOACs either directly inhibit clotting factors II (e.g., dabigatran) or X (e.g., apixaban, rivaroxaban, edoxaban). Although more expensive than warfarin, DOACs are attractive alternatives

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Section: Discussionmentioning

confidence: 99%

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Grewal

Atzema

Austin

et al. 2021

CMAJ

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“…Warfarin is the anticoagulant of choice in APS, and a recent study has demonstrated a threefold reduction in recurrent thrombosis in patients treated with warfarin versus DOACs [ 9 ]. However, warfarin has also been associated with an increase in the likelihood of an intracranial hemorrhage compared to DOACs [ 10 ]. This is a clinical dilemma for the patient due to the known prevalence of intracranial aneurysms (ICA) in ADPKD [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

Antiphospholipid Syndrome in a Patient With Autosomal Dominant Polycystic Kidney Disease: The Surface of the Moon

Dayco¹,

Shahzad²,

Tran³

et al. 2022

Cureus

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Antiphospholipid syndrome (APS) is a rare coagulopathic disorder diagnosed with a combination of clinical/imaging findings with specific antibody titer elevations over a period of 12 weeks. The following case report will discuss the unusual and challenging hospital course of a patient with extensive autosomal dominant polycystic kidney disease (ADPKD) being treated for a multi-drug resistant urinary tract infection (UTI). The patient later developed multiple deep vein thrombosis (DVT) and was found to have antiphospholipid syndrome. Warfarin, the anticoagulant of choice for antiphospholipid syndrome, has a higher likelihood of intracerebral hemorrhage than direct oral anticoagulants. This is particularly challenging since patients with autosomal dominant polycystic kidney disease have a higher propensity to develop intracranial aneurysms (ICA).

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“…In addition, the importance of different injury mechanisms may differ between human and animal models. The use of large gyrencephalic species in Collagenase injection -Anticoagulation 12,13 -Endogenous haematoma clearance 26À28 -White matter injury and axonal degeneration 30 -Cell death including ferroptosis 37,38,40À42,104 -Perihaematomal oedema 27,48 -BBB impairment 20,22,45,47,51 -Inflammation 20,51,52,103,104 -Immunosuppression 59 -Gut-brain axis 61 -Cardiac complications 59 -Can be combined with comorbidities: dyslipidaemia, 20 streptozotocin-induced diabetes, 104 spontaneously hypertensive animals (incl. haematoma expansion) 5 Injection of blood components -Axonal degeneration 105 -Cell death 51 -Inflammation 51 -White matter injury 106 Laser-induced rupture of vessels -Anticoagulation 107 -Microbleeds 107 Cyclodextrin nanoparticle injection -Anticoagulation 14 -Microbleeds 14 Liquid polymer gel -Hypertension (with additional phenylephrine injection) 23 -Anticoagulation (with additional anticoagulant injection) 23 -Mass effect, haematoma expansion CCM/AVM-related transgenic mouse models -Reasonable modelling of the clinical situation -Vascular malformations 15,16,18…”

Section: Outstanding Questionsmentioning

confidence: 99%

“…However, that risk is reduced in patients treated with direct oral anticoagulants (DOACs) compared to warfarin ( Supplementary Table ). 11 Preclinical studies using collagenase- or laser-induced ICH in rodents have replicated the benefit of DOACs 12 and the effectiveness of reversing anticoagulation was examined in animal models. 13 In mice subjected to cerebral microbleeds, warfarin promoted deadly ICH, whereas DOACs increased microbleed burden without triggering long-term cognitive impairment.…”

Section: Aetiology Of Ichmentioning

confidence: 99%

“… (A) Rodent models Model Aetiological or pathophysiological mechanisms addressed, translational value Autologous blood injection Endogenous haematoma clearance 26 , 28 , 29 , 53 White matter injury and axonal degeneration 30 , 100 Cell death 29 , 51 , 101 , 102 Perihaematomal oedema 49 , 51 , 53 , 101 , 102 BBB impairment 22 , 45 , 47 , 49 Inflammation 28 , 49 , 51 , 52 , 53 , 101 , 102 , 103 Immunosuppression 58 Cardiac complications 63 , 64 Can be combined with comorbidities: angiotensin II infusion + hyperglycaemia (incl. haematoma expansion), 22 hyperglycaemia 102 Collagenase injection Anticoagulation 12 , 13 Endogenous haematoma clearance 26 , 27 , 28 White matter injury and axonal degeneration 30 ...…”

Section: Limitations Of Animal Modelsmentioning

confidence: 99%

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