Intracranial Haemorrhage in Patients on Antithrombotics: Clinical Presentation and Determinants of Outcome in a Prospective Multicentric Study in Italian Emergency Departments

Abstract

Background: Intracranial haemorrhage (ICH) is the type of stroke associated with the highest death rate, and about 30% of ICH occurs in patients on antithrombotic treatment. This study relates clinical presentations and outcome of ICH patients on oral anticoagulant (OA) or antiplatelet (AP) therapy admitted to 33 Italian emergency departments (ED). Methods: Consecutive patients were enrolled after cranial computed tomography (CT). Primary outcome was the Modified Rankin Scale (MRS) score at 3 months of follow-up. Common descriptive statistics were computed after stratification for traumatic or spontaneous ICH and identification of the anatomical location of bleeding. Multivariate logistic regression was used to assess predictors of death. Results: We recruited 434 patients on AP therapy and 232 on OA. There were 432 spontaneous and 234 traumatic ICH patients. The proportions of AP and OA patients undergoing neurosurgery were 21.8and 19.4%, respectively, while <30% underwent procoagulant medical treatment. At the 3-month follow-up, the case fatality rate was 42.0%, while disability or death (MRS 3–6) was 68.1%. The odds ratio for death in OA versus AP patients was 2.63 (95% CI 1.73–4.00) in the whole population and 2.80 (95% CI 1.77–4.41) in intraparenchymal event patients. Glasgow Coma Scale, age, spontaneous event and anticoagulant use were found to be predictors of death both in traumatic and spontaneous events. Conclusion: This study confirms the high prevalence of death or disability in OA and AP patients with ICH. As far as the determinants of mortality and disability are concerned, the results of this study might be useful in the clinical management and allocation of resources in the ED setting. The observed low use of procoagulant therapy highlights the need for ED educational programmes to heighten the awareness of available and effective haemostatic treatments.

Antithrombotic Therapy Influences Location, Enlargement, and Mortality from Intracerebral Hemorrhage

“…In addition, cessation of antithrombotic therapy during the acute phase of ICH may increase the incidence of fatal thromboembolic accidents. In contrast to previous studies [10], the statistical power of the effect of warfarin on mortality was smaller than that of antiplatelet agents. This difference is partly due to the fact that the admission INR value in warfarin users in the present study was generally low, and partly due to the fact that the effect of warfarin can be reversed suddenly using hemostatic agents.…”

“…In a study of recombinant activated factor VII in ICH, prior antiplatelet therapy was associated with hematoma growth when the growth was assessed as a categoric change, but it was not associated when the growth was assessed as absolute or percentage change [9]. In an Italian multicenter study, 3-month mortality after spontaneous ICH exceeded 50% in patients taking antiplatelet agents [10]. …”

Comparison of Outcomes of Nonsurgical Spontaneous Intracerebral Hemorrhage Based on Risk Factors and Physician Specialty

“…12 As previously reported, our study found that arteriovenous malformations, tumors, ad aneurysms are relatively rare risk factors as causes of ICH. 13 About 27% patients were on antiplatelet therapy and 8.5% on anticoagulation therapy at admission. This proportion is quite similar to an Italian study of 241 patients with ICH, where 19.5% were on antiplatelets and 11.2% on anticoagulants.…”

“…This proportion is quite similar to an Italian study of 241 patients with ICH, where 19.5% were on antiplatelets and 11.2% on anticoagulants. 14 Baldi et al 13 have suggested that about 30% of ICH occurs in patients on antithrombotic therapy (antiplatelet and anticoagulant). In the latter study, 30.4% of patients on antiplatelets and 48.6% of patients on oral anticoagulants died in the hospital.…”

Prothrombin Complex Concentrates for Urgent Anticoagulation Reversal in Patients with Intracranial Haemorrhage

“…2007-08; 36:259-265 264 still seems to be underused in daily clinical practice for the treatment of this potentially life-threatening complication [4,5,37] . A broader use of PCCs in this clinical setting should be encouraged.…”