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

  • Małgorzata M. MillerEmail author
  • Jessica Lowe
  • Muhib Khan
  • Muhammad U. Azeem
  • Susanne Muehlschlegel
  • Adalia H. Jun-O’Connell
  • Richard P. GoddeauJr.
  • Majaz Moonis
  • Danielle Gritters
  • Brian Silver
  • Nils Henninger
Original Article

Abstract

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).

Keywords

Warfarin Direct oral anticoagulants Intracranial hemorrhage 

Notes

Author Contributions

MMM was involved in the study design, data acquisition, data analysis and interpretation, and drafting the article; JL and MK were involved in data acquisition, data interpretation, and revision of the manuscript; MUA and DG performed data acquisition and revision of the manuscript; SM, AHJO, RPG, MM, and BS were involved in interpretation of data and revision of the manuscript; NH was involved in the study design, data acquisition, statistical analysis of the data, interpretation of data, and drafting the article. All authors have read and approved the submitted manuscript.

Sources of Support

Dr. Henninger is supported by K08NS091499 from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Dr. Muehlschlegel is supported by K23HD080971 from the NIH/National Institute of Child Health and Human Development (NICHD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of interest

Dr. Henninger reports grants from NINDS, personal fees from Omniox, Inc, personal fees from Portola Pharmaceuticals, Inc, outside the submitted work. Dr. Muehlschlegel reports grants from NIH/NICHD, other from BARD Inc, outside the submitted work. Dr. Silver reports other from Joint Commission, other from Women’s Health Initiative, other from NIH, personal fees from Medicolegal malpractice reviews, personal fees from Ebix, personal fees from MedLink, personal fees from Medscape, outside the submitted work. Dr. Miller, Dr. Lowe, Dr. Khan, Dr. Azeem, Dr. Jun-O’Connell, Dr. Goddeau, Dr. Moonis, Dr. Gritters have nothing to disclose.

Ethical Approval

Our investigation was approved by institutional review boards, and we were granted a Health Insurance Portability and Accountability Act waiver of informed consent at the University of Massachusetts and Spectrum Health.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2019

Authors and Affiliations

  • Małgorzata M. Miller
    • 1
    Email author
  • Jessica Lowe
    • 2
  • Muhib Khan
    • 2
  • Muhammad U. Azeem
    • 1
  • Susanne Muehlschlegel
    • 1
    • 3
    • 4
  • Adalia H. Jun-O’Connell
    • 1
  • Richard P. GoddeauJr.
    • 1
  • Majaz Moonis
    • 1
  • Danielle Gritters
    • 5
  • Brian Silver
    • 1
  • Nils Henninger
    • 1
    • 6
  1. 1.Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Division of Neurology, Neuroscience InstituteSpectrum HealthGrand RapidsUSA
  3. 3.Department of SurgeryUniversity of Massachusetts Medical SchoolWorcesterUSA
  4. 4.Department of Anesthesia and Critical CareUniversity of Massachusetts Medical SchoolWorcesterUSA
  5. 5.Spectrum Health Office of ResearchSpectrum HealthGrand RapidsUSA
  6. 6.Department of PsychiatryUniversity of Massachusetts Medical SchoolWorcesterUSA

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