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Neurology. 2017 Sep 12;89(11):1142-1151. doi: 10.1212/WNL.0000000000004362. Epub 2017 Aug 16.

Direct oral anticoagulant- vs vitamin K antagonist-related nontraumatic intracerebral hemorrhage.

Author information

1
From the Department of Neurology (G.T., N.G., A.K., J.C., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., S.T., M.I., A.B.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (V.-A.L., C.N.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurology (P.V., C.M., M.J., P.M.), Henry Ford Hospital, Detroit, MI; Department of Neurology (A.H.K., S.G.), University of Ioannina School of Medicine, Greece; International Clinical Research Center (R.M.), Neurology Department, St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.B.), Dresden University Stroke Center; Department of Neurology (C.K., C.S.), St. Josef-Hospital, Ruhr University of Bochum, Germany; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (K.V.), Democritus University of Thrace, Alexandroupolis, Greece; Department of Neurology (E.D., A.P.), University of Thessaly, Larissa; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotelian University of Thessaloniki; Acute Stroke Unit (O.K.), Metropolitan Hospital, Piraeus; Laboratory of Haematology and Blood Bank Unit (A.T.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia; and Department of Neurology (P.M.), University of Crete, Heraklion, Greece. tsivgoulisgiorg@yahoo.gr.
2
From the Department of Neurology (G.T., N.G., A.K., J.C., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., S.T., M.I., A.B.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (V.-A.L., C.N.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurology (P.V., C.M., M.J., P.M.), Henry Ford Hospital, Detroit, MI; Department of Neurology (A.H.K., S.G.), University of Ioannina School of Medicine, Greece; International Clinical Research Center (R.M.), Neurology Department, St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.B.), Dresden University Stroke Center; Department of Neurology (C.K., C.S.), St. Josef-Hospital, Ruhr University of Bochum, Germany; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (K.V.), Democritus University of Thrace, Alexandroupolis, Greece; Department of Neurology (E.D., A.P.), University of Thessaly, Larissa; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotelian University of Thessaloniki; Acute Stroke Unit (O.K.), Metropolitan Hospital, Piraeus; Laboratory of Haematology and Blood Bank Unit (A.T.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia; and Department of Neurology (P.M.), University of Crete, Heraklion, Greece.

Abstract

OBJECTIVE:

To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF).

METHODS:

We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH.

RESULTS:

We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6-21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA2DS2-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3-14] vs 15 [7-25] points, p = 0.003), median baseline hematoma volume (12.8 [4-40] vs 24.3 [11-58.8] cm3, p = 0.007), and median ICH score (1 [0-2] vs 2 [1-3] points, p = 0.049). Severe ICH (>2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13-0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = -0.57, 95% CI -1.02 to -0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21-0.91, p = 0.030).

CONCLUSIONS:

DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH.

PMID:
28814457
DOI:
10.1212/WNL.0000000000004362
[Indexed for MEDLINE]

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