Background:
Use of antiplatelet medications and warfarin has been associated with poor clinical outcomes in spontaneous intracerebral hemorrhage (ICH). However, a head to head comparison between these groups has not been performed. We compared ICH outcomes among patients on these medications.
Methods:
In this cohort study, we analyzed 987 patients with ICH from the Virtual International Stroke Trials Archive. Patients with ICH presented within six-hours of symptom onset had baseline clinical, radiological data, and computed tomographic scan at 72 hours. Hematoma expansion was defined as interval increase in size by >33%. Main outcome variables were 90-day mortality, and modified Rankin Score (mRS) at 90 days dichotomized into 0-3 vs 4-6.
Results:
Of 987 ICH patients 154 had prior antiplatelet use, 30 had warfarin, and 803 had neither of the two medications. The warfarin group had significantly higher age (p<0.001) and higher prevalence of atrial fibrillation (p<0.001). Of the ICH characteristics, comparing warfarin, antiplatelet and no warfarin/antiplatelet cohorts, the warfarin group had lower Glasgow coma scale (GCS) scores (p=0.049), higher intraventricular hemorrhage (IVH) rate (p=0.010), and more hydrocephalus (p<0.001). Hematoma expansion at 72 hours was significantly higher with warfarin use (p=0.003), while the ratio of perihematomal edema volume to hematoma volume at 72 hours was lowest with warfarin use (p<0.001). In the logistic regression model adjusted for age, sex, race, hematoma volume, perihematomal edema, GCS, IVH and hydrocephalus; warfarin patients had significantly lower odds of achieving mRS 0-3 (OR: 0.23, 95% CI: 0.06-0.83, p=0.025), while the antiplatelet group had similar functional outcomes compared to no warfarin/antiplatelet use (OR: 0.75, 95% CI: 0.46-1.23, p=0.260). The 90-day mortality outcomes were not significantly different across the three groups (18.7% to 40.3%, p=0.520).
Conclusion:
Warfarin use is associated with a higher incidence of hydrocephalus, intraventricular hemorrhage and hematoma expansion, but lesser perihematomal edema relative to the hematoma volume. Warfarin associated ICH appears to be independently associated with worse functional outcomes but not with 90-day mortality in ICH.
Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage
