Warfarin-related intraventricular hemorrhage

Abstract

Objective: Oral anticoagulation therapy (OAT) with warfarin increases mortality and disability after intracerebral hemorrhage (ICH), the result of increased ICH volume and risk of hematoma expansion. We investigated whether OAT also influences risk of development of intraventricular hemorrhage (IVH), the volume of IVH and IVH expansion, and whether IVH is a substantive mediator of the overall effect of OAT on ICH outcome. Methods:We performed a retrospective analysis of a prospectively collected single-center cohort of 1,879 consecutive ICH cases (796 lobar, 865 deep, 153 cerebellar, 15 multiple location, 50 primary IVH) from 1999 to 2009. ICH and IVH volumes at presentation, as well as hematoma expansion (Ͼ33% or Ͼ6 mL increase) and IVH expansion (Ͼ2 mL increase), were determined using established semiautomated methods. Outcome was assessed at 90 days using either the modified Rankin Scale or Glasgow Outcome Scale. Results:Warfarin use was associated with IVH risk, IVH volume at presentation, and IVH expansion in both lobar and deep ICH (all p Ͻ 0.05) in a dose-response relationship with international normalized ratio. Warfarin was associated with poor outcome in both lobar and deep ICH (p Ͻ 0.01), and Ͼ95% of this effect was accounted for by baseline ICH and IVH volumes, as well as ICH and IVH expansion. Conclusion: Warfarin increases IVH volume and risk of IVH expansion in lobar and deep ICH.These findings (along with effects on ICH volume and expansion) likely represent the mechanisms by which anticoagulation worsens ICH functional outcome. Neurology ® 2011;77:1840-1846 GLOSSARY AUC ϭ area under the curve; CI ϭ confidence interval; GCS ϭ Glasgow Coma Scale; GOS ϭ Glasgow Outcome Scale; ICH ϭ intracerebral hemorrhage; INR ϭ international normalized ratio; IVH ϭ intraventricular hemorrhage; MGH ϭ Massachusetts General Hospital; mRS ϭ modified Rankin Scale; OAT ϭ oral anticoagulation therapy; OR ϭ odds ratio; ROC ϭ receiver operator characteristic.Baseline hematoma volume and intraventricular hemorrhage (IVH) are potent predictors of outcome after spontaneous intracerebral hemorrhage (ICH).1-3 Hematoma enlargement and IVH expansion following presentation also worsen mortality and disability. 4,5 ICH in the setting of oral anticoagulation therapy (OAT) has almost twice the mortality compared to non-warfarin-related ICH. 6 The mechanisms underlying the effect of warfarin on ICH outcome are still not completely understood.7 While the underlying coagulopathy clearly plays a role in worsening the severity of OAT-ICH, patients on OAT often have higher rates of comorbidities, which may themselves influence ICH outcome. Hematoma expansion has been consistently found to be more frequent in OAT-ICH, and there is suggestive evidence that warfarin use is associated with larger ICH volume at presentation. 8 -10 We investigated whether OAT is associated with increased risk of developing IVH, as well as with increased IVH volume at presentation and rates of IVH expansion over time. Next, we

Antithrombotic medications and the etiology of intracerebral hemorrhage

“…First, they confirm that ICH is common in patients treated with antithrombotic drugs, independent of the anatomical location of bleeding. Furthermore, in our series like in prior studies, 8,15,16 a relevant proportion of ICH among those on OACs occurred when the INR values were in the therapeutic range. Second, they support previous observations that OAC-related ICHs occur with a slightly more frequent lobar location.…”

Warfarin associated intracerebral hemorrhage in Hong Kong Chinese

“…The demographics, associated medical disorders and sites of hemorrhage of our patients are consistent with other WICH reports. [11][12][13][14][15][16][17][19][20][21] The mortality rate of WICH in our cohort at 30 days and 3-6 months were 58.0% and 62.0% respectively, which is on the higher side of reported range of 43.0-67%. 7,12,13,15,16,[19][20][21][22] Only 28.0% of patients with WICH had good neurological outcome with the remaining 10.0% being survivors with severe neurological disabilities.…”

“…12 Reported poor prognostic factors for WICH include INR . 3.0, 13,14 large hematoma volume, [14][15][16] intraventricular hemorrhage, 17 advanced age, 11 and low Glasgow coma scale (GCS) score on presentation. 15,16 However, findings in different studies vary.…”

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage

“…Patient registration years ranged from 1993 to 2014, with 90% of patients from 2004 to 2013. Registry methods are summarized in Supplementary Table I, with further details previously published 2, 3, 4, 14, 15, 16, 17, 18, 19, 20…”