Introduction: The risks, benefits and impact on outcome of anticoagulation following spontaneous intracerebral hemorrhage (ICH) are not well established.
Methods: Prospectively collected data of ICH patients on full-dose anticoagulation at ictus or after ICH were reviewed between 5/2013 and 4/2016. Composite ischemic (ischemic stroke, venous thromboembolism or myocardial infarction) and hemorrhagic (GI bleed, anemia requiring transfusion, new intracerebral hemorrhage) complications and 12-month modified Rankin scores were compared between those anticoagulated versus not post-ICH.
Results: Of 174 ICH patients, 54 (31%) were anticoagulated at ictus (N=38 on warfarin; N=13 on heparin/LMWH, N=9 on novel oral anticoagulant [NOAC]). Twenty-five patients were anticoagulated post-ICH in a median of 22 days (range 3-271); 16/54 [30%] resumed anticoagulation, 9 patients started anticoagulation de novo (N=17 warfarin, N=7 NOAC and N=1 LMWH) and 38/54 (70%) did not resume anticoagulation. Compared to those who did not resume anticoagulation, anticoagulated patients were younger, had better ICH and APACHE-2 scores and were more likely to undergo ICH evacuation (all P<0.05). Composite ischemic events trended lower in anticoagulated patients (0.03 versus 0.73 events per patient-year in non-anticoagulated, P=0.093) and there was no difference in composite hemorrhage events (0.17 in anti-coagulated versus 0.63 events per patient-year in non-anticoagulated, P=0.417). Recurrent intracerebral hemorrhage post-discharge occurred in 3 (12%) anticoagulated versus 0 non-anticoagulated patients (P=0.03) in a median of 102 days (range 24-263). In multivariable logistic regression analysis adjusting for ICH score and ICH evacuation, and excluding those who underwent withdrawal of life-sustaining therapy, resumption of anticoagulation was protective against death at 12-months (aOR 0.1, 95% CI 0.02-0.9, P=0.047).
Conclusions: Anticoagulation post-ICH is associated with fewer ischemic events, but more recurrent ICH post-discharge compared to non-resumption in previously anticoagulated patients. However, mortality rates were lower at 12-months in those who were anticoagulated, even after adjusting for ICH score and ICH evacuation.