Introduction: Intracerebral hemorrhage (ICH) is the most feared complication of anticoagulation. Risk markers, causes, characteristics, and outcome of acute direct oral anticoagulants (DOAC) ICH are an active field of investigation. We assessed these characteristics in patients with acute DOAC-ICH vs. vitamin K antagonist-associated ICH (VKA-ICH) and non-anticoagulant ICH.
Methods: Consecutive patients admitted to our Stroke centre with acute ICH (September 2013-May 2017) were screened. Outcomes were mortality and poor functional outcome (defined as mRS≥4) at discharge. Baseline clinical/imaging variables and outcome were compared between DOAC-ICH and VKA-ICH groups. We also compared these groups to spontaneous ICH (n=395). In DOAC-ICH we reviewed the presence of potential imaging markers of high ICH risk.
Results: We included 124 patients: 20 DOAC-ICH and 104 VKA-ICH. The two groups were similar in baseline demographics and vascular risk factors. There was no difference in median baseline ICH volume in DOAC-ICH vs. VKA-ICH (median: 16.5 ml, IQR: 4.4-40.1 vs. 18.6 ml, IQR: 3.6-46.5; p=0.877). Hematoma location was more often deep/brainstem in DOAC-ICH vs. VKA-ICH (80% vs. 45% respectively; p<0.001). The discharge mortality was higher (but not significant) for DOAC-ICH vs. VKA-ICH group (50% vs. 37.5%; p=0.295). The two groups had similar rates of poor functional outcome at discharge (90% vs. 92.3%; p=0.729). Compared to spontaneous ICH, DOAC-ICH and VKN-ICH had higher mortality at discharge (27% vs. 55%; p=0.022 and 27% vs. 37%; p=0.029 respectively). Eight DOAC-ICH had brain MRIs available. 7/8 patients showed evidence of microbleeds: multiple in a mixed distribution (i.e. both deep and lobar) in 4, strictly deep in 2 and strictly lobar in one patient. Two patients had evidence of cortical superficial siderosis. All DOAC-ICH patients had white matter hyperintensities on MRI or CT, with moderate-to-severe lesions in 71%.
Conclusion: ICH volume, mortality and functional outcome are similar for DOAC-ICH and VKA-ICH, but their outcomes are worse than non-anticoagulant ICH. High ICH risk markers seem to be common on imaging in the majority of DOAC-ICH, and tend to occur in deep brain regions, a clinically relevant hypothesis-generating finding.