doi: 10.1161/hs1101.098523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Stroke. 2001;32:2567.)
© 2001 American Heart Association, Inc.
Original Contributions |
Management and Prognostic Features of Intracerebral Hemorrhage During Anticoagulant Therapy
A Swedish Multicenter Study
From the Departments of Internal Medicine (L.S.) and Neurology (H.-G.H.) at Uppsala University Hospital, Uppsala; the Department of Neurology at Lund University Hospital (A.L., B.N.), Lund, and Örebro University Hospital (M.S.), Örebro; and the Departments of Internal Medicine at Kungälv Hospital (M.F.), Kungälv, Sahlgrenska University Hospital (L.S., D.S.), Göteborg, Mölndal Hospital (A.T.), Mölndal, Falu Hospital (L.W.), Falu, and Sundsvall Hospital (J.W.), Sundsvall, Sweden.
Correspondence to Hans-Göran Hårdemark, MD, PhD, Department of Neurology, Center of Clinical Neurosciences, University Hospital, S 751 85 Uppsala, Sweden. E-mail H-G.Hardemark{at}neurologi.uu.se
Background and Purpose—— Patients treated with oral anticoagulants (ACs) have an increased risk of intracerebral hemorrhage (ICH), which is more often fatal than spontaneous ICH. Options to reverse the AC effect include intravenous administration of vitamin K, plasma, and coagulation factor concentrate. However, the optimal management of AC-related ICH has not been determined in any randomized trial. In this study, the present management of AC-related ICH was surveyed, and determinants of survival were assessed.
Methods—— We retrospectively reviewed the medical records of all AC-related ICHs at 10 Swedish hospitals during a 4-year period, 1993 to 1996. Survival status after the ICH was determined from the Swedish National population register.
Results—— We identified 151 patients with AC-related ICH. Death rates were 53.6% at 30 days, 63.6% at 6 months, and 77.5% at follow-up (mean 3.5 years). The case fatality ratio at 30 days was 96% among patients unconscious on admission (n=27), 80% among patients who became unconscious before active treatment was started (n=15), 55% among patients in whom no special action was taken except withdrawal of AC treatment (n=42), and 28% among patients given active anti-coumarin treatment while they were still conscious (n=64). The case fatality ratio at 30 days was 11% in the group treated with plasma (n=18), 30% in the group treated with vitamin K (n=23), and 39% in the group treated with coagulation factor concentrate (n=23). Within the first 24 to 48 hours after admission, 47% of the patients deteriorated. Choice of therapy to reverse the AC effect differed substantially between the hospitals (P<0.0001), as did the time interval from symptom onset to start of treatment. Multiple logistic regression analysis showed only 2 factors (intraventricular extension of bleeding and ICH volume) that were independently related to case fatality at both 30 days and 6 months. The results were similar when the analysis was restricted to patients who were conscious on admission.
Conclusions—— In AC-related ICH, a progressive neurological deterioration during the first 24 to 48 hours after admission is frequent, and the mortality is high. Choice of therapy to reverse the AC effect differed considerably between the hospitals. There was no evidence that any treatment strategy was superior to the others. A randomized controlled trial is needed to determine the best choice of treatment.
Key Words: anticoagulants • cerebral hemorrhage • prognosis • tomography, x-ray computed
This article has been cited by other articles:
 |
|
 |
|
  M. L. Flaherty, O. Adeoye, P. Sekar, M. Haverbusch, C. J. Moomaw, H. Tao, J. P. Broderick, and D. Woo The Challenge of Designing a Treatment Trial for Warfarin-Associated Intracerebral Hemorrhage Stroke, May 1, 2009; 40(5): 1738 - 1742. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Foerch, K. Arai, G. Jin, K.-P. Park, S. Pallast, K. van Leyen, and E. H. Lo Experimental Model of Warfarin-Associated Intracerebral Hemorrhage Stroke, December 1, 2008; 39(12): 3397 - 3404. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Cucchiara, S. Messe, L. Sansing, S. Kasner, P. Lyden, and for the CHANT Investigators Hematoma Growth in Oral Anticoagulant Related Intracerebral Hemorrhage Stroke, November 1, 2008; 39(11): 2993 - 2996. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Broderick, S. Connolly, E. Feldmann, D. Hanley, C. Kase, D. Krieger, M. Mayberg, L. Morgenstern, C. S. Ogilvy, P. Vespa, et al. REPRINT: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, October 16, 2007; 116(16): e391 - e413. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Thompson, S. Y. Gerlach, H. K. S. Jorn, J. M. Larson, T. G. Brott, and J. A. Files Advances in the Care of Patients With Intracerebral Hemorrhage Mayo Clin. Proc., August 1, 2007; 82(8): 987 - 990. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Broderick, S. Connolly, E. Feldmann, D. Hanley, C. Kase, D. Krieger, M. Mayberg, L. Morgenstern, C. S. Ogilvy, P. Vespa, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke, June 1, 2007; 38(6): 2001 - 2023. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. N. Goldstein, L. E. Fazen, R. Snider, K. Schwab, S. M. Greenberg, E. E. Smith, M. H. Lev, and J. Rosand Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage Neurology, March 20, 2007; 68(12): 889 - 894. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. A. Rabinstein and E. F. M. Wijdicks Determinants of Outcome in Anticoagulation-Associated Cerebral Hematoma Requiring Emergency Evacuation Arch Neurol, February 1, 2007; 64(2): 203 - 206. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. I. Aguilar, R. G. Hart, C. S. Kase, W. D. Freeman, B. J. Hoeben, R. C. Garcia, J. E. Ansell, S. A. Mayer, B. Norrving, J. Rosand, et al. Treatment of Warfarin-Associated Intracerebral Hemorrhage: Literature Review and Expert Opinion Mayo Clin. Proc., January 1, 2007; 82(1): 82 - 92. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. B. Huttner, P. D. Schellinger, M. Hartmann, M. Kohrmann, E. Juettler, J. Wikner, S. Mueller, U. Meyding-Lamade, R. Strobl, U. Mansmann, et al. Hematoma Growth and Outcome in Treated Neurocritical Care Patients With Intracerebral Hemorrhage Related to Oral Anticoagulant Therapy: Comparison of Acute Treatment Strategies Using Vitamin K, Fresh Frozen Plasma, and Prothrombin Complex Concentrates Stroke, June 1, 2006; 37(6): 1465 - 1470. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. E. Gerber, S. A. Grossman, and M. B. Streiff Management of Venous Thromboembolism in Patients With Primary and Metastatic Brain Tumors J. Clin. Oncol., March 10, 2006; 24(8): 1310 - 1318. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Alemany, A. Stenborg, A. Terent, P. Sonninen, and R. Raininko Coexistence of Microhemorrhages and Acute Spontaneous Brain Hemorrhage: Correlation with Signs of Microangiopathy and Clinical Data Radiology, January 1, 2006; 238(1): 240 - 247. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. C. Hemphill III Treating Warfarin-Related Intracerebral Hemorrhage: Is Fresh Frozen Plasma Enough? Stroke, January 1, 2006; 37(1): 6 - 7. [Full Text] [PDF]
|
|
|
|
|
|
T. Steiner, J. Rosand, and M. Diringer Intracerebral Hemorrhage Associated With Oral Anticoagulant Therapy: Current Practices and Unresolved Questions Stroke, January 1, 2006; 37(1): 256 - 262. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. D. Freeman, T. G. Brott, K. M. Barrett, P. R. Castillo, H. G. Deen Jr, L. F. Czervionke, and J. F. Meschia Recombinant Factor VIIa for Rapid Reversal of Warfarin Anticoagulation in Acute Intracranial Hemorrhage Mayo Clin. Proc., December 1, 2004; 79(12): 1495 - 1500. [Abstract] [PDF]
|
|
|
|
 |
|
 J P Hanley Warfarin reversal J. Clin. Pathol., November 1, 2004; 57(11): 1132 - 1139. [Abstract] [Full Text] [PDF]
|
|