Prediction of functional outcome and in-hospital mortality after admission with oral anticoagulant-related intracerebral hemorrhage

Anticoagulation medication in nontraumatic intracranial hemorrhage survivors with atrial fibrillation

BACKGROUND

The relative effectiveness of anticoagulation agents in patients with atrial fibrillation (AF) who survive an intracranial hemorrhage (ICH) is unknown. This study was performed to examine the comparative effectiveness of different oral anticoagulation (OAC) on clinical outcomes in this group of patients.

METHODS

We performed a Bayesian network meta-analysis of randomized controlled trials (RCTs) and observational studies comparing different OAC (direct oral anticoagulant [DOAC] and warfarin) for the treatment of patients with AF who sustained ICH. Outcomes included repeat ICH, thromboembolic events, and all-cause mortality. The values derived from the surface under the cumulative ranking curve were obtained to rank the treatment hierarchy.

RESULTS

We identified 12 studies (two RCTs and ten observational studies) involving 23,265 patients; 346 patients were treated with any OAC agents; 5,006 received DOAC; 5,271 received warfarin; 12,007 received antiplatelet or no therapy, and 635 did not received relevant therapy. Both DOAC and warfarin (RR, 0.58; 95% CI, 0.45-0.74; RR, 0.83; 95% CI, 0.69-0.98) were superior to antiplatelet or no therapy in preventing thromboembolic events. Moreover, DOAC also showed superiority in preventing thromboembolic events (RR, 0.70; 95% CI, 0.58-0.83), repeat ICH (RR, 0.52; 95% CI, 0.40-0.67), and all-cause mortality (RR, 0.51; 95% CI, 0.46-0.56) than warfarin.

CONCLUSIONS

Our study suggests DOACs may be a reasonable alternative to anti-platelet therapy and warfarin for patients with AF who experienced ICH. However, given the available evidence is primarily observational, further validation by ongoing trials directly comparing these two classes of drugs are needed.

2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

Clinical and Radiological Characteristics of Vitamin K Versus Non-Vitamin K Antagonist Oral Anticoagulation-Related Intracerebral Hemorrhage

BACKGROUND/OBJECTIVE

Recent studies indicated that functional outcome after intracranial hemorrhage (ICH) related to direct oral anticoagulation (DOAC-ICH) is similar, if not better, than vitamin K antagonist (VKA)-related ICH (VKA-ICH) due to a smaller initial hematoma volume (HV). However, the association with hematoma expansion (HE) and location is not well understood.

METHODS

We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to determine HV and HE stratified by hematoma location, and the relation to the 90-day outcome.

RESULTS

DOAC-ICH (n = 25) and VKA-ICH (n = 77) had a similar admission HV and HE (unadjusted p > 0.05, each). Targeted reversal strategies were used in 93.5% of VKA-ICH versus 8% of DOAC-ICH. After adjustment, an unfavorable 90-day functional outcome (modified Rankin scale score 4-6) was independently associated with a lower admission Glasgow Coma Scale score (OR 1.63; 95% CI 1.26-2.10; p < 0.001) and greater HV (OR 1.03; 95% confidence interval (CI) 1.00-1.05; p = 0.046). After exclusion of patients without follow-up head computed tomography to allow for adjustment by occurrence of HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95% CI 1.01-13.09; p = 0.048). However, there was no significant association of the oral anticoagulant strategy with 90-day outcome in the entire cohort (OR 2.85; 95% CI 0.69-11.86; p = 0.15).

CONCLUSIONS

DOAC use did not relate to worse HE, HV, and functional outcome after ICH, adding to the notion that DOAC is a safe alternative to VKA even in the absence of access to targeted reversal strategies (which are still not universally available).

Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy

The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear. The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed. Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04-1.10), previous stroke (HR 1.83; 95% CI 1.14-2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16-9.74) and GCS 9-12 (HR 3.38; 95% CI 1.81-6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61-2.76), VKAs (HR 1.42; 95% CI 0.70-2.88) or DOACs (HR 1.28; 95% CI 0.61-2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death. In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.

Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies

Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis

Background

Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction.

Methods

PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models.

Results

Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures.

Conclusions

Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0613-8) contains supplementary material, which is available to authorized users.

Comparing intracerebral hemorrhages associated with direct oral anticoagulants or warfarin

OBJECTIVES

This cross-sectional survey explored the characteristics and outcomes of direct oral anticoagulant (DOAC)-associated nontraumatic intracerebral hemorrhages (ICHs) by analyzing a large nationwide Japanese discharge database.

METHODS

We analyzed data from 2,245 patients who experienced ICHs while taking anticoagulants (DOAC: 227; warfarin: 2,018) and were urgently hospitalized at 621 institutions in Japan between April 2010 and March 2015. We compared the DOAC- and warfarin-treated patients based on their backgrounds, ICH severities, antiplatelet therapies at admission, hematoma removal surgeries, reversal agents, mortality rates, and modified Rankin Scale scores at discharge.

RESULTS

DOAC-associated ICHs were less likely to cause moderately or severely impaired consciousness (DOAC-associated ICHs: 31.3%; warfarin-associated ICHs: 39.4%; p = 0.002) or require surgical removal (DOAC-associated ICHs: 5.3%; warfarin-associated ICHs: 9.9%; p = 0.024) in the univariate analysis. Propensity score analysis revealed that patients with DOAC-associated ICHs also exhibited lower mortality rates within 1 day (odds ratio [OR] 4.96, p = 0.005), within 7 days (OR 2.29, p = 0.037), and during hospitalization (OR 1.96, p = 0.039).

CONCLUSIONS

This nationwide study revealed that DOAC-treated patients had less severe ICHs and lower mortality rates than did warfarin-treated patients, probably due to milder hemorrhages at admission and lower hematoma expansion frequencies.

Predicting Prognosis of Intracerebral Hemorrhage (ICH): Performance of ICH Score Is Not Improved by Adding Oral Anticoagulant Use

Background

The intracerebral hemorrhage (ICH) score is a commonly used prognostic model for 30-day mortality in ICH, based on five independent predictors (ICH volume, location, Glasgow Coma Scale, age, and intraventricular extension). Use of oral anticoagulants (OAC) is also associated with mortality but was not considered in the ICH score. We investigated (a) whether the predictive performance of ICH score is similar in OAC-ICH and non-OAC-ICH and (b) whether addition of OAC use to the ICH score increases the prognostic performance of the score.

Methods

We retrospectively selected all consecutive adult non-traumatic ICH cases (three hospitals, region South-Limburg, the Netherlands 2004-2009). Mortality at 30 days was recorded. Using univariable and multivariable logistic regression, association between OAC use and 30-day mortality was tested. Then (a) we computed receiver operating characteristic (ROC) curves for ICH score and determined the area under the curve (AUC) in OAC-ICH and non-OAC-ICH. Then (b) we created a New ICH score by adding OAC use to the ICH score. We calculated correlation between 30-day mortality and ICH score, respectively, New ICH score using Spearman correlation test. We computed ROC curves and calculated the AUC.

Results

We analyzed 1,232 cases, 282 (22.9%) were OAC related ICH. Overall, 30-day mortality was 39.3%. OAC use was independently associated with 30-day mortality (OR 2.09, 95% CI, 1.48-2.95; p < 0.001), corrected for the five predictors of the ICH score. The ICH score performed slightly better in non-OAC-ICH (AUC 0.840) than in OAC-ICH (AUC 0.816), but this difference was not significant (p = 0.39). The ICH score and the New ICH score were both significantly correlated with 30-day mortality (rho 0.58, p < 0.001 and 0.59, p < 0.001, respectively). The AUC for the ICH score was 0.837, for New ICH score 0.840. This difference was not significant.

Conclusion

The ICH score is a useful tool for predicting 30-day mortality both in patient who use and patients who do not use OAC. Although OAC use is an independent predictor of 30-day mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score.

Before-After Study of an Electronic Order Set for Reversal of Vitamin K Antagonist-Associated Intracerebral Hemorrhage

Background

Vitamin K antagonist (VKA)-associated intracerebral hemorrhages (ICHs) are more likely to expand and are associated with higher mortality than primary ICH. Prompt reversal of anticoagulant effect with prothrombin complex concentrate (PCC) may promote hemostasis and decrease hematoma expansion. The aim of this study was to evaluate the impact of an electronic order set designed to standardize and facilitate more timely reversal of coagulopathy in VKA-associated ICH.

Methods

We identified all adults who received PCC for VKA-associated ICH from June 2012 to June 2015 at University of California San Francisco Medical Center, which included a period before and after an electronic order set became available in 2014. We abstracted baseline demographics and clinical data from electronic health records. The primary outcome was time from radiographic identification of ICH to administration of PCC.

Results

Thirty-one patients received PCC for VKA-associated ICH, including 17 patients before and 14 patients after the order set became available. Baseline demographics and clinical features were similar. Order set use was associated with a significant decrease in the time from identification of ICH on imaging to the administration of PCC (median 83 vs 45 minutes; P = .02), more accurate dosing (29.4% vs 92.9%; P < .01), and a shorter time from the PCC order to follow-up international normalized ratio (INR) testing (median 164 vs 85 minutes, P = .001).

Conclusion

An electronic order set for administering PCC for VKA-associated ICH was associated with significantly faster time to PCC administration and increased dosing accuracy.

Clinical management and outcome of major bleeding in patients on treatment with vitamin K antagonists

BACKGROUND

The optimal management of major bleeding associated with vitamin K antagonists remains unclear.

OBJECTIVES

The aim of the study was to assess the determinants of outcome of vitamin K antagonists-associated major bleeding and the outcome of bleeding in relation with the therapeutic management.

METHODS

Patients hospitalized for major bleeding while on vitamin K antagonists were included in a prospective, cohort study. Major bleeding was defined according to the criteria of the International Society of Thrombosis Haemostasis. The primary study outcome was death at 30days from major bleeding.

RESULTS

544 patients were included in this study, of which 282 with intracranial hemorrhage. Prothrombin complex concentrates were used in 51% and in 23% of patients with intracranial hemorrhage or non-intracranial major bleeding, respectively (p<0.001); fresh frozen plasma was used in 7% and in 17% of patients with intracranial hemorrhage or non-intracranial major bleeding (p<0.001). Death at 30days occurred in 100 patients (18%), 72 patients with intracranial hemorrhage and 28 patients with non-intracranial major bleeding. Age over 85years, low Glasgow Coma Scale score and shock were independent predictors of death at 30days. Invasive procedures were associated with decreased risk of death.

CONCLUSIONS

Among the patients hospitalized for major bleeding while on vitamin K antagonists, the risk for death is substantial. The risk for death is associated with the clinical severity of major bleeding as assessed by the GCS score and by the presence of shock more than with the initial localization of major bleeding (ICH vs other sites).

Cost-Effectiveness of Echocardiography to Identify Intracardiac Thrombus among Patients with First Stroke or Transient Ischemic Attack

Background and Purpose . Echocardiography to select stroke patients for targeted treatments, such as anticoagulation (AC), to reduce recurrent stroke risk is controversial. The authors' objective was to evaluate the cost-effectiveness of imaging strategies that use transthoracic (TTE) and transesophageal (TEE) echocardiography for identifying intracardiac thrombus in new stroke patients. Methods . Model-based cost-effectiveness analysis of 7 echocardiographic imaging strategies and 2 nontesting strategies with model parameters based on systematic evidence review related to effectiveness of echocardiography in newly diagnosed ischemic stroke patients (white males aged 65 years in base case). Primary outcome was cost per quality-adjusted life year (QALY). Results . All strategies containing TTE were dominated by others and were eliminated from the analysis. Assuming that AC reduces recurrent stroke risk from intracardiac thrombus by 43% over 1 year, TEE generated a cost per QALY of $137,000 (relative to standard treatment) among patients with 5% thrombus prevalence. Cost per QALY dropped to $50,000 in patients with at least 15% intracardiac thrombus prevalence, or, if an 86% relative risk reduction with AC is assumed, in patients with thrombus prevalence of at least 6%. Probabilistic analyses indicate considerable uncertainty around the cost-effectiveness of echocardiography across a wide range of intracardiac thrombus prevalence (pretest probability). Conclusions . Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke patients. Additional research on recurrent stroke risk in patients with intracardiac thrombus and on the efficacy of AC in reducing that risk may contribute to a better understanding of the circumstances under which echocardiography will be cost-effective. Key words: cost-effectiveness; decision analysis; stroke; transesophageal echocardiography; transthoracic echocardiography; diagnostic imaging. (Med Decis Making 2007;27:161—177)

Epidemiology of Intracranial Haemorrhages Associated with Vitamin K Antagonist Oral Anticoagulants in Spain: TAC Registry

BACKGROUND

Vitamin K antagonist oral anticoagulants (VKA-OACs) are effective for primary and secondary prevention of embolic events. The rate of haemorrhagic neurological complications in patients admitted to neurology departments in Spain is not yet known.

AIMS

We aimed to determine the clinical and epidemiological characteristics of patients with intracranial haemorrhage secondary to VKA-OACs as well as the incidence of this severe complication.

METHODS

We conducted a retrospective, descriptive, multi-centre study using information from the medical records of all patients admitted to neurology departments, diagnosed with spontaneous intracranial haemorrhage, and treated with VKA-OACs within a 1-year period. We collected demographic and care data from centres, patients' medical records [demographic data, medical history, haemorrhage origin, vascular risk factors, concomitant treatment, and National Institutes of Health Stroke Scale (NIHSS) scores], and patients' outcome at 3 months [independence (modified Rankin Scale score <3) and mortality rate].

RESULTS

Twenty-one hospitals serving a population of 8,155,628 inhabitants participated in the study. The total number of cases was 235, the mean age was 78.2 (SD 9.4) years, and the baseline NIHSS score was 11.6 (SD 9.5; median 9; interquartile range 14). The VKA-OACs used were acenocoumarol in 95.3% (224 patients) and warfarin in 4.7% (11 patients). The haemorrhage origin was deep in 29.8%, lobar in 25.5%, intraventricular in 11.5%, extensive in 17.4% (>100 ml), cerebellar in 12.3%, and in the brainstem in 3.4%. The international normalised ratio was within therapeutic ranges at admission (according to indication) in 29.4% (69 patients). The global incidence (cases per 100,000 inhabitants per year) is 2.88. The in-hospital mortality rate was 40%, and 24.3% of the patients were independent at 3 months, while the mortality at 3 months was 42.6%.

CONCLUSION

VKA-OAC treatment is associated with a large percentage of all cases of spontaneous intracranial haemorrhage, an event leading to high dependence and mortality rates.

Antiplatelet and anticoagulant therapy after intracerebral hemorrhage

Management of patients with an indication for long-term oral antithrombotic therapy who have an intracerebral hemorrhage (ICH) presents a therapeutic dilemma. Should antithrombotic therapy be resumed, and if so, when, using what agent, and for whom? There is no consensus for answers to these questions. In the absence of randomized trials, management of antithrombotic therapy after ICH is based on a combination of observational data, pathophysiologic concepts, and decision analysis. At the heart of the decision is an assessment of the individual patient's risk of thromboembolism off antithrombotic therapy versus risk of ICH recurrence on antithrombotic therapy.

Long-term bleeding events after mechanical aortic valve replacement in patients under the age of 60

BACKGROUND

Although younger patients are supposed to be less susceptible to bleeding complications of mechanical aortic valve replacement (mAVR) than older patients, there is a relative paucity of data on this subject. Therefore, it remains uncertain whether younger patients are really at a lower risk of these complications than older patients.

METHODS

Incidence rates of bleeding events during 15 years of follow-up after mAVR were compared between 163 patients under 60 (group I), 122 patients between 60 and 65 (group II), and 145 patients over 65 (group III) years of age at operation. The target international normalised ratio (INR) was 3.0-4.0.

RESULTS

During 15 years of follow-up, the annual incidence rate of major bleeding events (excluding haemorrhagic stroke) was lower in the youngest as compared with the oldest group (3.0 versus 4.7 %, respectively; p = 0.030). However, the annual incidence rate of haemorrhagic stroke was as high in the youngest as in the two older groups (0.6 versus 0.7 % and 0.7 %, respectively; p = 0.928).

CONCLUSIONS

With a target INR of 3.0-4.0, patients under 60 years of age are at equally high risk of haemorrhagic stroke after mAVR as older patients. This finding confirms the relevance of a lower target INR as used in international guidelines.

Location and characteristics of warfarin associated intracranial hemorrhage

Objective

In the so-called primary intracerebral hemorrhage (ICH), lobar and deep ICH were mainly due to cerebral amyloid angiopathy and deep perforating arterial disease. Our aim was to identify specifics of warfarin associated ICH (WAICH) and to focus on differences in susceptibility to warfarin according to the underlying vasculopathies, expressed by ICH location.

Materials and Methods

We identified all subjects aged ≥ 18 years who were admitted with primary ICH between January 1, 2007 and September 30, 2012. We retrospectively collected demographic characteristics, the presence of vascular risk factors and pre-ICH medication by chart reviews. We categorized ICH into four types according to location: lobar, deep, posterior fossa, and undetermined. We investigated characteristics (including hematoma volume and expansion) of ICH according to the location of ICH.

Results

WAICH accounted for 35 patients (5.6%) of 622 ICH cases. In WAICH, 13 patients (37.1%) had lobar ICH and 22 patients (60.0%) had non-lobar ICH. Compared to other locations of ICH, lobar ICH showed an excess risk of WAICH (OR 2.53, 95% CI 1.03-6.21, p = 0.042). The predictors of lobar location of ICH were warfarin (OR 2.29, 95% CI 1.05-5.04, p = 0.038) and diabetes mellitus (DM) (OR 0.54, 95% CI 0.29-0.98, p = 0.044). The lobar location of ICH showed significant association with larger hematoma volume (p = 0.001) and high ratio of hematoma expansion (p = 0.037) compared with other locations of ICH.

Conclusion

In our study, warfarin showed significant association with lobar ICH and it caused larger hematoma volume and more expansion of hematoma in lobar ICH.

Warfarin-associated intracerebral hemorrhage: volume, anticoagulation intensity and location

BACKGROUND

Warfarin use increases mortality in patients with intracerebral hemorrhage (ICH). Larger hematoma volume and infratentorial location are both major determinants of poor outcome in ICH. Although warfarin-associated intracerebral hemorrhages have greater volumes, there is uncertainty about the effects of location. We aimed to investigate the influence of warfarin on hematoma volume and location.

METHODS

We conducted a retrospective study of all patients hospitalized for ICH at a large stroke center from October 2007 to January 2012. Initial CT scans were used to quantify hematoma volumes using the computer-assisted planimetric analysis. Univariate and multivariable analyses determined the influence of warfarin on hemorrhage location. Median regression analysis was performed to estimate the effects of INR on hematoma volumes.

RESULTS

We included 404 consecutive patients with ICH of whom 69 were on warfarin. Patients on warfarin had larger hematoma volumes (median 23.9mL vs. 14.2mL; P=0.046). In patients excessively anticoagulated with warfarin (defined as INR>3.0), compared with those in the therapeutic range, brainstem ICH was more frequent (24.0% vs. 6.1%; P=0.005). Patients with INR>3.0 had increased odds of infratentorial hemorrhage (OR 3.63; 95% CI 1.52-8.64; P=0.004) when compared to non-warfarin ICH patients. After adjustment for hematoma location, there was no significant association between INR and hematoma volume.

CONCLUSIONS

Patients with warfarin-associated ICH have a predilection for brainstem ICH. After adjustment for ICH location, no relationship between admission INR and hematoma volume was found.

Intracerebral hemorrhage in patients receiving oral anticoagulation therapy

Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.

Individual characteristics and management decisions affect outcome of anticoagulated patients with intracranial hemorrhage

BACKGROUND

Anticoagulated patients with intracranial hemorrhage represent a major management challenge. Our goal is to determine how patient characteristics and management decisions influence outcome.

METHODS

A systematic review of the literature identified relevant reported cases. Variables describing patient characteristics, management, and outcome were extracted. Statistical analyses were carried out using analysis of variance and Fisher's exact test.

RESULTS

A total of 242 patients from our updated dataset met inclusion criteria. Tissue plane of the hemorrhage (P < 0.0001), indication for anticoagulation (P < 0.0001), type of anticoagulant (P = 0.0173), and history of hypertension (P = 0.0418) were significantly associated with outcome. Older age (P < 0.0001), supratentorial index hemorrhages (P = 0.0018), failure to restart anticoagulation (P < 0.0001), and larger hematoma volume (P < 0.0001) were associated with worse outcome. Surgical evacuation was associated with improved outcome (P = 0.0011). There was a trend toward an association between the occurrence of a hemorrhagic or thromboembolic complication and risk of death (P = 0.0882). Sex and sidedness of the index hemorrhage were not significantly associated with outcome.

CONCLUSIONS

Our results provide prognostic information that may assist management of these patients. Our results also suggest that it may be unwise to withhold anticoagulation indefinitely after an index hemorrhage. As thromboembolic or hemorrhagic complications may be associated with worse outcome, efforts to avoid them may be wise. The studies that comprise our dataset have important limitations and a prospective study will be required to confirm these results.

Traumatic brain injury during warfarin anticoagulation: an experimental study in mice

The number of patients who are on long-term anticoagulation therapy while experiencing traumatic brain injury (TBI) is rising. This experimental study evaluated whether warfarin pre-treatment increases brain hemorrhage and worsens functional outcome after TBI, and whether the rapid reversal of anticoagulation after TBI prevents warfarin-exacerbated brain damage. Normal CD-1 mice (C) and mice pre-treated with warfarin (W) to an International Normalized Ratio of 3.5±0.9 underwent TBI using a controlled cortical impact model. Mean hemorrhage volume 24 h after TBI was 1.2±0.4 μL in C mice and 10.9±6.9 μL in W mice (p=0.029, n=4 per group). In a second study, anticoagulated mice received either saline (W-S) or prothrombin complex concentrate (W-PCC, 100 U/kg) intravenously 60 min after TBI. Anticoagulation reversal using PCC (W-PCC mice) reduced hemorrhage volumes as compared to W-S animals (7.3±6.0 versus 19.8±14.0 μL, p=0.045, n=8 per group). In a third study, we examined motor deficits and lesion volume in C, W-S, and W-PCC mice until 33 days after injury. Functional outcome and lesion volume were no different between groups (n=10 per group). In conclusion, we characterized an experimental model of TBI occurring during warfarin anticoagulation. Anticoagulation led to higher intracerebral blood volumes, but did not significantly worsen functional outcome. The rapid reversal of anticoagulation may be effective in preventing excess bleeding.

Symptomatologic versus neuroimaging predictors of in-hospital survival after intracerebral haemorrhage

Symptomatological prediction of Intracerebral haemorrhage (ICH) mortality is a simple and effective method compared to pathological predictors. In this study we considered consciousness level as an easily measurable predictor and compared it to haemorrhage location, intraventricular penetration and haemorrhage size derived from Computerized Tomography (CT) to predict mortality using a parametric survival analysis model. Two hundred and thirty eight ICH patients from a neurology hospital ward were enrolled into this comparative study. Patient history was documented with respect to mortality and a questionnaire outlining background variables and medical history was completed for them. Consciousness level was clinically evaluated by a physician while haemorrhage size and location were determined via computerized tomographic scanning reports. Data were entered into the computer and analyzed according to the Weibull parametric survival analysis model using STATA 8 statistical software. Males constituted 47.1% of the 238 patients, 52.9% were females. The age range of the patients varied from 13 to 88 years, with a mean age of 62.4 +/- 13.6 (Mean +/- SD). Half of the patients survived more than 20 days. Using the Weibull regression model, the only significant independent symptomatological predictor of mortality was found to be the level of consciousness. Cumulative hazard during the 90 days was compared for different levels of consciousness. Application of Weibull to pathological predictors of ICH mortality showed that the two independent predictors were haemorrhage size and intraventricular penetration. Results of statistical modelling didn't provide evidence of priority for pathological predictors of survival compared to easily measurable levels of consciousness as a symptomatological predictor. Easily measurable symptoms of level of consciousness can be used as a survival predictor of stroke due to intra-cerebral haemorrhage when compared to pathological indicators.

Management of intracranial bleeding in anticoagulated patients

Intracranial haemorrhage is a life-threatening complication of anticoagulation. When the anticoagulation is for a mechanical heart valve the risks of further bleeding on warfarin need to be balanced against the risks of thromboembolism from an unprotected valve.

Specificity and reliability of prognostic indexes in intensive care evaluation: the spontaneous cerebral haemorrhage case

OBJECTIVE

To determine the reliability of a generic index such as Simplified Acute Physiology Score II (SAPSII), compared with a specific one Intra Cerebral Haemorrhage score (ICH score), as an intensive care unit (ICU) outcome predictor when evaluating a general facility that frequently treats a specific type of patients - those with spontaneous cerebral haemorrhage.

METHODS

The study cohort consisted of a random sample of patients (81) admitted to Modena's Policlinico Teaching Hospital's ICU with spontaneous ICH over a 24-month period. Main outcome measure SAPSII, ICH score, overall mortality.

RESULTS

The mean ICH score for the 32 surviving patients was 3.41 +/- 1.012 while for the 49 deceased patients was of 4.24 +/- 0.855 (P = 0.000). The mean SAPSII value for the 32 surviving patients was 49.09 +/- 16.58 while for the 49 deceased patients was 49.51 +/- 15.93. SAPSII, ICH scores were analysed for mortality, by receiver operating characteristic curves: the area under the curve was significant for ICH, not-significant for SAPSII.

CONCLUSIONS

Regional quality controls use generic prognostic indexes (SAPSII) in relation to mortality and outcome to assess ICUs, which is appropriate when dealing with a general facility when there is not a predominant type of patient, but it may bias the evaluation if the population with specific pathologies (ICH), not included in the general index, is statistically considerable, leading to an incorrect criticality assessment, an inappropriate strategic plan and the subsequent inefficient resource allocation.

The challenge of designing a treatment trial for warfarin-associated intracerebral hemorrhage

BACKGROUND AND PURPOSE

Warfarin-associated intracerebral hemorrhage (WICH) became more frequent in the past 2 decades. Interest in potential WICH treatment trials has grown, but the practicality of such trials has received less attention. We determined the number of patients that would be eligible for enrollment in hypothetical treatment trials for WICH using a population-based study.

METHODS

We identified all patients aged 18 years or older from the Greater Cincinnati/Northern Kentucky region with nontraumatic intracerebral hemorrhage in 2005. Three hypothetical WICH treatment trial criteria sets were used to determine eligibility for enrollment, varying from relatively strict to broadly inclusive. For the hypothetical trials, we assumed the comparison of a standard therapy to an alternative therapy. Sample size calculations assumed different rates of poor outcome depending on the criteria set, various effect sizes, a 2-sided alpha of 0.05, and 80% power. Given 5 years of trial enrollment, the population base needed to enroll the required subjects was then calculated.

RESULTS

Warfarin-associated intracerebral hemorrhage accounted for 54 of 286 (19%) cases of intracerebral hemorrhage within the Greater Cincinnati/Northern Kentucky region in 2005. Eligibility rates ranged from 2 of 54 WICH patients (4% of cases, strictest set) to 11 of 54 WICH patients (20% of cases, most inclusive set). Given these rates, a population base of at least 67 million persons would be required to conduct a 5-year trial for WICH with a 10% effect size using a moderately strict criteria set.

CONCLUSIONS

Any planned treatment trial for WICH should anticipate significant challenges in successfully enrolling adequate numbers of patients.

OUTCOME PREDICTORS AND SPECTRUM OF TREATMENT ELIGIBILITY WITH PROSPECTIVE PROTOCOLIZED MANAGEMENT OF INTRACEREBRAL HEMORRHAGE

OBJECTIVE

Risk predictors, spectrum of treatment eligibility, and range of expected outcomes have not been validated in consecutive series including all cases of intracerebral hemorrhage (ICH) subjected to a prospective management protocol based on current guidelines.

METHODS

Eighty-six cases of ICH were prospectively identified in conjunction with screening for a clinical trial during an 18-month period. All patients were subjected to protocolized management based on published “best practice” guidelines for ICH. Medical records were reviewed by trained researchers, and outcomes were assessed at various time points including latest follow-up (range, 0–24 months; mean, 3.97 months). Initial assessment parameters, treatment eligibility, and outcomes were based on standardized criteria.

RESULTS

In accordance with past literature, mortality and functional outcomes were significantly worse in older patients, those with a larger ICH volume, and worse Glasgow Coma Scale scores, in univariate and multivariate models. The presence and severity of associated intraventricular hemorrhage also correlated with mortality and outcome. Significantly lower mortality (P = 0.024) and better functional outcomes (P = 0.018) were achieved at 30 days in patients with an ICH volume of less than 30 cm3 in this series than in previously published community-based historical controls without protocolized care. A tight correspondence between treatment eligibility and treatment administered was found.

CONCLUSION

Previous estimates of poorer outcome in patients with ICH might not apply to contemporary management protocols, especially in patients with a smaller ICH volume. Outcome ranges in various risk categories and modeling of treatment eligibility will help project more realistic prognostication and assist with the design of future trials.

Warfarin use leads to larger intracerebral hematomas

BACKGROUND

Among patients with intracerebral hemorrhage (ICH), warfarin use before onset leads to greater mortality. In a retrospective study, we sought to determine whether warfarin use is associated with larger initial hematoma volume, one determinant of mortality after ICH.

METHODS

We identified all patients hospitalized with ICH in the Greater Cincinnati region from January through December 2005. ICH volumes were measured on the first available brain scan by using the abc/2 method. Univariable analyses and a multivariable generalized linear model were used to determine whether international normalized ratio (INR) influenced initial ICH volume after adjusting for other factors, including age, race, sex, antiplatelet use, hemorrhage location, and time from stroke onset to scan.

RESULTS

There were 258 patients with ICH, including 51 patients taking warfarin. In univariable comparison, when INR was stratified, there was a trend toward a difference in hematoma volume by INR category (INR <1.2, 13.4 mL; INR 1.2-2.0, 9.3 mL; INR 2.1-3.0, 14.0 mL; INR >3.0, 33.2 mL; p = 0.10). In the model, compared with patients with INR <1.2, there was no difference in hematoma size for patients with INR 1.2-2.0 (p = 0.25) or INR 2.1-3.0 (p = 0.36), but patients with INR >3.0 had greater hematoma volume (p = 0.02). Other predictors of larger hematoma size were ICH location (lobar compared with deep cerebral, p = 0.02) and shorter time from stroke onset to scan (p < 0.001).

CONCLUSION

Warfarin use was associated with larger initial intracerebral hemorrhage (ICH) volume, but this effect was only observed for INR values >3.0. Larger ICH volume among warfarin users likely accounts for part of the excess mortality in this group.

Experimental model of warfarin-associated intracerebral hemorrhage

BACKGROUND AND PURPOSE

Future demographic changes predict an increase in the number of patients with atrial fibrillation. As long-term anticoagulation for the prevention of ischemic strokes becomes more prevalent, the burden of warfarin-associated intracerebral hemorrhage (W-ICH) is likely to grow. However, little is known about the clinical aspects and pathophysiologic mechanisms of W-ICH. This study describes the development of a mouse model of W-ICH in which hematoma growth and outcomes can be correlated with anticoagulation parameters.

METHODS

CD-1 mice were treated with warfarin (2 mg/kg per 24 hours) added to drinking water. ICH was induced by stereotactic injection of collagenase type VII (0.075 U) into the right striatum. Hemorrhagic blood volume was quantified by means of a photometric hemoglobin assay 2 and 24 hours after hemorrhage induction. Neurologic outcomes were assessed on a 5-point scale.

RESULTS

The international normalized ratio in nonanticoagulated mice was 0.8+/-0.1. After 24 (W-24) and 30 (W-30) hours of warfarin pretreatment, international normalized ratio values increased to 3.5+/-0.9 and 7.2+/-3.4, respectively. Compared with nonanticoagulated mice, mean hemorrhagic blood volume determined 24 hours after hemorrhage induction was found to be 2.5-fold larger in W-24 mice (P=0.019) and 3.1-fold larger in W-30 mice (P<0.001, n=10 per group). Mortality at 24 hours after hemorrhage induction was 0% in nonanticoagulated mice, 10% in W-24 mice, and 30% in W-30 mice. Hematoma enlargement between 2 and 24 hours after hemorrhage induction was -1.4% for nonanticoagulated mice, 22.9% for W-24 mice, and 62.2% for W-30 mice.

CONCLUSIONS

This study characterizes the first experimental model of W-ICH. It may be helpful in gaining further insights into the pathophysiology of W-ICH and may be used for testing the efficacy of treatment strategies, such as hemostatic therapy, in this severe subtype of stroke.

Death and disability from warfarin-associated intracranial and extracranial hemorrhages

OBJECTIVES

Little is known about the outcomes of patients who have hemorrhagic complications while receiving warfarin therapy. We examined the rates of death and disability resulting from warfarin-associated intracranial and extracranial hemorrhages in a large cohort of patients with atrial fibrillation.

METHODS

We assembled a cohort of 13,559 adults with nonvalvular atrial fibrillation and identified patients hospitalized for warfarin-associated intracranial and major extracranial hemorrhage. Data on functional disability at discharge and 30-day mortality were obtained from a review of medical charts and state death certificates. The relative odds of 30-day mortality by hemorrhage type were calculated using multivariable logistic regression.

RESULTS

We identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 person-years of warfarin exposure. At hospital discharge, 76% of patients with intracranial hemorrhage had severe disability or died, compared with only 3% of those with major extracranial hemorrhage. Of the 40 deaths from warfarin-associated hemorrhage that occurred within 30 days, 35 (88%) were from intracranial hemorrhage. Compared with extracranial hemorrhages, intracranial events were strongly associated with 30-day mortality (odds ratio 20.8 [95% confidence interval, 6.0-72]) even after adjusting for age, sex, anticoagulation intensity on admission, and other coexisting illnesses.

CONCLUSIONS

Among anticoagulated patients with atrial fibrillation, intracranial hemorrhages caused approximately 90% of the deaths from warfarin-associated hemorrhage and the majority of disability among survivors. When considering anticoagulation, patients and clinicians need to weigh the risk of intracranial hemorrhage far more than the risk of all major hemorrhages.

Frequency of adverse events in patients with poor anticoagulation: a meta-analysis

BACKGROUND

Patients taking anticoagulants orally over the long term have international normalized ratios (INRs) outside the individual therapeutic range more than one-third of the time. Improved anticoagulation control will reduce hemorrhagic and thromboembolic event rates. To gauge the potential effect of improved anticoagulation control, we undertook to determine the proportion of anticoagulant-associated events that occur when INRs are outside the therapeutic range.

METHODS

We conducted a meta-analysis of all studies that assigned hemorrhagic and thromboembolic events in patients taking anticoagulants to discrete INR ranges. We identified studies using the MEDLINE (1966-2006) and EMBASE (1980-2006) databases. We included studies reported in English if the majority of patients taking oral anticoagulants had an INR range with a lower limit between 1.8 and 2 and an upper limit between 3 and 3.5, and their INR at the time of the hemorrhagic or thromboembolic event was recorded.

RESULTS

The final analysis included results from 45 studies (23 that reported both hemorrhages and thromboemboli; 14 that reported hemorrhages only; and 8, thromboemboli only) involving a median of 208 patients (limits of interquartile range [25th-75th percentile] 131-523 subjects; total n = 71 065). Of these studies, 64% were conducted at community practices; the remainder, at anticoagulation clinics. About 69% of the studies were classed as having moderate or high quality. Overall, 44% (95% confidence interval [CI] 39%-49%) of hemorrhages occurred when INRs were above the therapeutic range, and 48% (95% CI 41%-55%) of thromboemboli took place when below it. The mean proportion of events that occurred while the patient's INR was outside the therapeutic range was greater for studies with a short mean follow-up (< 1 yr). Between-study heterogeneity was significant (p < 0.001).

INTERPRETATION

Improved anticoagulation control could decrease the likelihood of almost half of all anticoagulant-associated adverse events.

Oral anticoagulant treatment: risk factors involved in 500 intracranial hemorrhages

Intracranial bleeding is the most severe complication caused by anticoagulant or antiplatelet treatment. The increasing use of this therapy, especially in older people, makes the balance between clinical benefit and bleeding risk an important consideration. A retrospective study of all consecutive 500 intracranial hemorrhages in the West Valladolid area, approximately 220,000 people, during the period 1998 to 2004, was performed. In relation to mortality, predisposing conditions were included, such as age, antithrombotic treatment, arterial hypertension, cancer, blood diseases, vascular malformations, and traumatisms. The incidence of intracranial hemorrhage was 310 per 100,000 per year with a mortality of 30%. Higher mortality was found in antiplatelet-treated patients (44.9%) than in anticoagulated patients (31.1%). This may be related to a different mean age of 78 vs. 71 years. Arterial hypertension was the most frequent risk factor (45.1% in nontreated patients, 60% anticoagulated, and 75.5% antiplatelet). The relative risk of intracranial bleeding in anticoagulated patients was 11.2 (p < 0.001) with an incidence of 0.03% and a median of 14 months since treatment began. The median INR was 3.3. In 40% of the patients the previous five controls were in range. Strict consideration of indications criteria joined to a better control of risk factors may avoid intracranial bleeding episodes.

[Intracerebral hemorrhage related to anticoagulant therapy]

Intracerebral hemorrhage (ICH) is the most serious complication of oral anticoagulant therapy (OAT). The growing use of OAT has resulted in an increase of fatal ICH. The mortality rate is about 65%, and most of the surviving patients remain disabled. While improvements in the treatment of spontaneous ICH have recently been described, there are no internationally accepted guidelines for managing patients with OAT-ICH. Therefore, identifying effective treatments is essential for improving clinical outcome. This article reviews the epidemiology of OAT-ICH, its pathophysiology, and current treatment options and discusses open questions with particular respect to more recent pharmacological therapies.

Prevalence and Characteristics of Adverse Drug Reactions in Neurosurgical Intensive Care Patients

OBJECTIVE:

To evaluate the prevalence and characteristics of adverse drug reactions (ADRs) in neurosurgical intensive care patients.

METHODS:

Retrospective analysis of ADR data obtained from a spontaneous reporting system in a tertiary care university hospital. Reports of suspected ADRs in adult patients admitted emergently or electively to the neurosurgical service were included.

RESULTS:

Over the 3 year period, 3496 neurosurgical intensive care unit (ICU) patient admissions accounted for 5% of all hospital admissions. A total of 10% of all neurosurgical patients developed a suspected ADR, with three patients experiencing multiple reactions. Other adult ICU patients developed ADRs at a comparable rate (9%, P&gt;0.05). Overall, neurosurgery patients accounted for 12% of all spontaneously reported ADRs. Preventable reactions were observed in 43 (13%) cases, and treatment was required for 76%. The majority (96%) of ADRs resolved or improved at the time of the ADR report. Nausea, pruritus, thrombocytopenia, and vomiting were most frequently noted. Therapies most often associated with reported events were analgesics, antipyretics, antibiotics, anticonvulsants, and histamine H2 antagonists. The relationship between central nervous system disease and adverse event occurrence is not clear.

CONCLUSION:

Despite the narrow scope of drug regimens in neurosurgical ICU patients, ADRs can complicate therapy in this critically ill population. Neurosurgical ICU patients seem to experience ADRs no more frequently than their adult ICU counterparts.

Prognostic Significance of Blood Brain Barrier Permeability in Acute Hemorrhagic Stroke

BACKGROUND

Blood brain barrier (BBB) disruption is accompanied by edema in the surrounding areas of the intracerebral hemorrhage (ICH). The aim of the study was to clarify the correlation between BBB breakdown and outcome in ICH.

PATIENTS

Twenty-seven patients with primary ICH were included in the study. Each patient underwent CT and DTPA-SPECT, and the National Institutes of Health (NIH) and modified Rankin score were performed as well.

RESULTS

DTPA-SPECT had a significant correlation with the modified Rankin score after 3 months (p = 0.008) and 6 months (p = 0.01). The CT scan was directly correlated with the NIH score on days 1, 7 and 30 (p = 0.01, p = 0.01 and p = 0.04, respectively). No correlation was found between DTPA-SPECT and CT scan data.

CONCLUSIONS

The degree of BBB breakdown, as imaged by the DTPA-SPECT technique, was directly correlated with the late functional outcome. The CT scan has an inverse correlation with the NIH score. These findings may have broad clinical implications.

Applicability and relevance of models that predict short term outcome after intracerebral haemorrhage

OBJECTIVES

Several models for prediction of short term outcome after intracerebral haemorrhage (ICH) have been published, however, these are rarely used in clinical practice for treatment decisions. This study was conducted to identify current models for prediction of short term outcome after ICH and to evaluate their clinical applicability and relevance in treatment decisions.

METHODS

MEDLINE was searched from 1966 to June 2003 and studies were included if they met predefined criteria. Regression coefficients of multivariate models were extracted. Two neurologists independently evaluated the models for applicability in clinical practice. To assess clinical relevance and accuracy of each model, in a validation series of 122 patients the proportion with a >or=95% probability of death or poor outcome and the actual 30 day case fatality in these patients were calculated. Receiver operator characteristic (ROC) curves were computed for assessment of discriminatory power.

RESULTS

A total of 18 prognostic models were identified, of which 14 appeared easy to apply. In the validation series, the proportion of patients with a >or=95% probability of death or poor outcome ranged from 0% to 43% (median 23%). The 30 day case fatality in these patients ranged from 75% to 100% (median 93%). The area under the ROC curves ranged from 0.81 to 0.90.

CONCLUSIONS

Most models are easy to apply and can generate a high probability of death or poor outcome. However, only a small proportion of patients have such a high probability, and 30 day case fatality is not always correctly predicted. Therefore, current models have limited relevance in triage, but can be used to estimate the chances of survival of individual patients.