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A retrospective study has revealed insights that may help physicians manage patients with anticoagulant-associated intracerebral hemorrhage.
Attaining an international normalized ratio (INR) below 1.3 and systolic blood pressure below 160 mm Hg, both within 4 hours of hospital admission, were associated with lower rates of hematoma enlargement.
And resuming anticoagulant therapy conferred a lower risk of ischemic events without increasing bleeding complications.
Hagen B. Huttner, MD, of the University of Erlangen-Nuremberg in Erlangen, Germany, and his colleagues published these findings in JAMA.
The investigators noted that, among all types of stroke, there is a substantial lack of data about how to manage oral-anticoagulant-related intracranial hemorrhage. Two of the most pressing questions are how to prevent hematoma enlargement and how to manage anticoagulation in the long-term.
There is a consensus that elevated INR levels should be reversed to minimize hematoma enlargement, but the mode of reversal, timing, and extent of INR reversal are unclear. And valid data on the safety and clinical benefit of resuming oral anticoagulant use have not been established.
So Dr Huttner and his colleagues conducted their study to gain some insight. They looked at patients treated at 19 German tertiary care centers from 2006 to 2012, assessing long-term functional outcomes in 1176 patients, hematoma enlargement in 853 patients, and anticoagulant resumption in 719 patients.
Thirty-six percent of patients experienced hematoma enlargement. Patients were less likely to experience enlargement if they had achieved INR levels below 1.3 within 4 hours of hospital admission. Enlargement occurred in 19.8% of these patients, compared to 41.5% of other patients (P<0.001).
Patients were also less likely to have hematoma enlargement if their systolic blood pressure was lower than 160 mm Hg at 4 hours after admission. Enlargement occurred in 33.1% of these patients and 52.4% of other patients (P<0.001).
Patients who had both of these favorable factors had even lower rates of hematoma enlargement than patients with higher INR and blood pressure levels—18.1% and 44.2%, respectively (P<0.001). And having both favorable factors conferred a lower rate of in-hospital mortality as well—13.5% and 20.7%, respectively (P=0.03).
About 24% of patients resumed oral anticoagulant therapy. Those who did had fewer ischemic complications than their peers—5.2% and 15%, respectively (P<0.001). But there was no significant difference between the groups with regard to hemorrhagic complications—8.1% and 6.6%, respectively (P=0.48).
The investigators concluded that, although this study has revealed clinically valuable associations, the results must be replicated in prospective studies.
