Background: Novel oral anticoagulant (NOAC) use has significantly reduced Intracerebral Hemorrhagic (ICH) risk compared to standard anticoagulant treatment. Increased ICH hematoma expansion (HE) is a known predictor of mortality in warfarin associated ICH. Little is known about ICH expansion in patients using NOACs.
Methods: We conducted a retrospective chart review of patients with ICH admitted to CSMC from Oct 2010 through March 2015. We identified patients with concomitant administration of either a NOAC or warfarin and collected data including the following: reason for agent prescription, time to brain imaging, evidence of HE on imaging, and discharge status and mRS at discharge. We defined HE as either relative expansion (≥ 33% increase) or absolute expansion (≥ 12 mL). We compared outcomes of patients with and without HE.
Results: Out of 642 patients admitted with ICH within this time period, we identified 7 patients with concomitant NOAC use and a sample of 14 matched patients on warfarin. Patients on NOACs vs warfarin patients had no significant differences in NIHSS or ICH score on presentation (median [IQR] 21 [11,22] vs 16 [5,26] and 2 [1,4] vs 2 [1,2]). 4 out of 7 coagulopathic NOAC patents demonstrated HE, compared to 5 out of the 14 warfarin patients that demonstrated HE, with no significant difference. Of the NOAC subset, the median NIHSS on presentation was 21 [13,23.5] and the median ICH score on presentation was 2 [2,4]. There were no significant differences in mRS on discharge in NOAC patient with HE vs without or warfarin patients with HE vs without (5 [4,6] vs. 5.5 [4.5,6] and 4 [3.5,6] vs 3 [3,5.5]).
Conclusions: In our coagulopathic NOAC patient population, HE continues beyond 6 hours in 57% of patients. To our knowledge, this is the largest case series reporting on HE with concomitant NOAC use. This case series was not statistically powered to show significant differences between groups, although outcomes in patients suffering from HE appear to be poor in general. Expansion of the initial hematoma is a possible target for medical intervention. The better outcomes in warfarin patients in our cohort are likely related to the targeted reversal of coagulopathy.