Poor outlook for ICH associated with novel oral anticoagulants

By Eleanor McDermid, Senior medwireNews Reporter

Haematoma expansion, disability and death are common among patients who have intracerebral haemorrhage (ICH) while taking novel oral anticoagulants, a study in JAMA Neurology shows.

Of the 61 patients enrolled in the prospective, multicentre study, 16% died during acute hospitalisation and 28% died within 3 months. And of the survivors, 65% had a poor outcome, with a modified Rankin Scale score of 3–5.

The patients were aged an average of 76.1 years and had a median admission National Institutes of Health Stroke Scale score of 10.

The median time between symptom onset and baseline imaging was 21.1 hours. Yet Roland Veltkamp (Imperial College London, UK) and study co-authors found that on repeat imaging, between 3 and 72 hours later, 38% of the patients had significant haematoma expansion (at least 33% or 6 mL). Furthermore, 7% had developed intraventricular extension and 11% had a “relevant increase” in intraventricular bleeding.

In a linked editorial, Stephan Mayer (Icahn School of Medicine at Mount Sinai, New York, USA) says the prospective imaging provides “valuable insights” into the bleeding process in these patients, indicating that it is “often a gradual and prolonged, ‘oozing’ type of process, in contrast to the explosive syndromes that result from spontaneous hypertensive ICH.”

He says: “The implication for clinical care is that protocols for emergency reversal of [novel oral anticoagulants] in patients with intracranial bleeding should not be restricted to patients presenting within an early time window.”

Emergency reversal “should be mandatory for all patients presenting within 48 hours of symptom onset”, Mayer suggests.

About half (57%) of the patients in the study received 4-factor prothrombin complex concentrate in an effort to halt bleeding. But treatment did not reduce the likelihood of haematoma expansion, which occurred in 43% of those treated and 29% of those not given prothrombin complex concentrate, and neither did it improve outcomes.

The researchers note that patients given prothrombin complex concentrate had a significantly poorer clinical status than those not treated, and more often had deep haemorrhage, which, along with the small sample size, may have explained the lack of benefit.

Mayer concedes that the “preliminary returns do not look very promising”, but notes that idarucizumab has been approved for reversal of dabigatran anticoagulation, and other drugs are in development.

But Veltkamp and team caution: “It remains to be shown that successful reversal of anticoagulation translates into improved clinical outcome via prevention of hematoma expansion.”

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