Resumption of Direct Oral Anticoagulants in Patients with Acute Spontaneous Intracerebral Hemorrhage

Background: Intracerebral Hemorrhage (ICH) accounts for 10% of strokes annually in the United States (US). Up-to-date trends in disease burden and regional variation remain unknown; especially after a dramatic increase in the use of direct oral anticoagulants (DOACs) since 2010. Our study reports updated incidence, mortality and mortality to incidence ratio (MIR) data related to ICH across the US. Methods: This observational study utilized the Global Burden of Disease database to determine age-standardized incidence (ASIR), death (ASDR) and MIR rates for ICH overall and for each state in the US from 1990-2017. All analyses were stratified by sex. Trends were analyzed using Joinpoint regression analysis, with presentation of estimated annual percentage changes (EAPCs) in ASIRs, ASDRs and MIRs over the observation period. Results: We observed an overall decrease in ASIRs, ASDRs and MIRs in both genders from 1990-2017, apart from female ASIRs and ASDRs in West Virginia and Kentucky. In 2017, the mean ASIR per 100,000 population for men was 25.67 and 19.17 for women. The 2017 mean ASDRs per 100,000 population for men and women were 13.96 and 11.35, respectively. The District of Columbia had the greatest decreases in ASIR EAPCs for males at -41.25% and females at -40.58%, and the greatest decreases in ASDR EAPCs for both males and females at -55.38% and -48.51%, respectively. The overall MIR during the study period decreased in males by -12.12% and females by -7.43%. However, MIR increased in males from 2014-2017 (EAPC +2.2% [95% CI +0.9%-+3.5%]) and in females from 2011-2017 (EAPC +1.0% [CI +0.7%-+1.4%]). Conclusion: This report reveals overall decreasing trends in incidence, mortality and MIR from 1990-2017. Notably, no significant change in mortality was found in the last 6 years of the study period, and MIR worsened in males from 2014-2017 and in females from 2011-2017, suggesting decreased ICH related survival lately. The substitution of vitamin K antagonists with DOACs is one possible explanation for a downtrend in incidence despite an aging population and increased use of anticoagulants. Limited access to reversal agents for DOACs is a potential reason for increase in MIR, however concrete deductions cannot be made owing to the observational nature of the study.

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Anticoagulation in Acute Neurological Disease

Seminars in Neurology ◽

10.1055/s-0041-1733793 ◽

2021 ◽

Vol 41 (05) ◽

pp. 530-540

Author(s):

Cina Sasannejad ◽

Kevin N. Sheth

Keyword(s):

Intracerebral Hemorrhage ◽

Neurological Disease ◽

Sinus Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cerebral Venous Sinus Thrombosis ◽

Metabolic Complications ◽

Reversal Agents ◽

Clinical Scenarios ◽

Patients At Risk

AbstractWhile anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.

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Intracerebral Hemorrhage Formation Under Direct Oral Anticoagulants

Stroke ◽

10.1161/strokeaha.118.023722 ◽

2019 ◽

Vol 50 (4) ◽

pp. 1034-1042 ◽

Cited By ~ 2

Author(s):

Christian Foerch ◽

Eng H. Lo ◽

Klaus van Leyen ◽

Arne Lauer ◽

Jan Hendrik Schaefer

Keyword(s):

Intracerebral Hemorrhage ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Abstract TP349: Clinical Outcomes of Direct Oral Anticoagulants versus Warfarin in Patients With Atrial Fibrillation Who Have Had an Intracerebral Hemorrhage

Stroke ◽

10.1161/str.49.suppl_1.tp349 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Ravi Janumpally ◽

Arevik S Ambartsumyan ◽

Lewei Duan ◽

Derenik Gharibian ◽

Navdeep Sangha

Keyword(s):

Atrial Fibrillation ◽

Intracerebral Hemorrhage ◽

Clinical Outcomes ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Oral anticoagulants can improve the functional outcome in survivors of spontaneous intracerebral hemorrhage.

Pan Arab Journal of Neurosurgery ◽

10.21608/pajn.2021.74625.1020 ◽

2021 ◽

Vol 16 (2) ◽

pp. 64-70

Author(s):

Ahmed Salah ◽

Mostafa Motawe ◽

Ahmed Abdullah

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Oral Anticoagulants ◽

Spontaneous Intracerebral Hemorrhage

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Characteristics of Symptomatic Intracerebral Hemorrhage in Patient Receiving Direct Oral Anticoagulants: Comparison with Warfarin

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2017.12.020 ◽

2018 ◽

Vol 27 (5) ◽

pp. 1338-1342 ◽

Cited By ~ 16

Author(s):

Masahito Kawabori ◽

Yoshimasa Niiya ◽

Motoyuki Iwasaki ◽

Shoji Mabuchi ◽

Hiroyuki Ozaki ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Symptomatic Intracerebral Hemorrhage

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Atrial Fibrillation in Spontaneous Intracerebral Hemorrhage, Dijon Stroke Registry (2006–2017)

Journal of the American Heart Association ◽

10.1161/jaha.120.020040 ◽

2021 ◽

Author(s):

Amélie Gabet ◽

Valérie Olié ◽

Yannick Béjot

Keyword(s):

Atrial Fibrillation ◽

Intracerebral Hemorrhage ◽

Scale Score ◽

Oral Anticoagulants ◽

Temporal Trends ◽

Population Based ◽

Modified Rankin Scale ◽

Newly Diagnosed ◽

Spontaneous Intracerebral Hemorrhage ◽

Stroke Registry

Background Atrial fibrillation (AF) represents a major indication for oral anticoagulants (OAC) that contribute to spontaneous intracerebral hemorrhage (ICH). This study evaluated AF prevalence among patients with ICH, temporal trends, and early functional outcomes and death of patients. Methods and Results Patients with first‐ever ICH were prospectively recorded in the population‐based stroke registry of Dijon, France, (2006–2017). Association between AF and early outcome of patients with ICH (ordinal modified Rankin Scale score and death at discharge) were analyzed using ordinal and logistic regressions. Among 444 patients with ICH, 97 (21.9%) had AF, including 65 (14.6%) with previously known AF treated with OAC, and 13 (2.9%) with newly diagnosed AF. AF prevalence rose from 17.2% (2006–2011) to 25.8% (2012–2017) ( P ‐trend=0.05). An increase in the proportion of AF treated with OAC (11.3% to 17.5%, P ‐trend=0.09) and newly diagnosed AF (1.5% to 4.2%, P ‐trend=0.11) was observed. In multivariable analyses, after adjustment for premorbid OAC, AF was not significantly associated with ordinal modified Rankin Scale score (odds ratio [OR], 1.29; 95% CI, 0.69–2.42) or death (OR, 0.89; 95% CI, 0.40–1.96) in patients with ICH. Nevertheless, adjusted premorbid OAC use remained highly associated with a higher probability of death (OR, 2.53; 95% CI, 1.11–5.78). Conclusions AF prevalence and use of OAC among patients with ICH increased over time. Premorbid use of OAC was associated with poor outcome after ICH, thus suggesting a need to better identify ICH risk before initiating or pursuing OAC therapy in patients with AF, and to develop acute treatment and secondary prevention strategies after ICH in patients with AF.

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