Abstract A104: Timely Door-To-Reversal in Anticoagulation-Associated Intracranial Hemorrhage: Rate limiting steps and predictors in a Multicenter Observational Study.

Introduction: Anticoagulant-associated intracranial hemorrhage (AA-ICrH) accounts for 10-25% of all intracranial hemorrhages, and anticoagulation use more than doubles mortality risk. Updated guidelines recommend that patients on anticoagulants should be reversed as soon as possible, however target treatment times remain underexplored. We aimed to breakdown the “door-to -reversal” (DTR) times at seven Comprehensive Stroke Centers (CSC) to identify key rate-limiting steps for a timely DTR process. Methods: An 18-month retrospective review of all consecutive AA-ICrH patients treated with reversal agents in emergency departments of the study CSCs between 2022 and 2023. Characteristics and predictors of the DTR process were evaluated in bivariate and multivariable linear regression models. Results: Of 115 AA-ICrH patients (median age 79 years; 50% male; 87% Caucasian), the median NIHSS and ICH scores were 12 IQR 5-21 and 2 IQR 1-3, respectively. Overall, 81% were on FXa inhibitors and 19% on warfarin. Reversal agents included andexanet alpha (43%) and prothrombin complex concentrates (56%). Arrival modes were ground ambulance (81%), helicopter (10%), and walk-in (5%). Arrival ≤3 hours from symptom onset occurred in 45%, and 55% were treated in a stroke alert (SA) protocol. Contact information, anticoagulant name, and time from last dose upon arrival were known in 62%, 77% and 19%, respectively. Median DTR and CT-to-reversal times were 102.5 IQR 65.5-156 and 66 IQR 47-107 minutes, respectively. DTR ≤60 minutes occurred in 28.3% of SA cases and 8.5% of non-SA cases. DTR was 99 IQR 62-152 minutes for ambulance/helicopter arrivals, and 199 112-297 minutes for walk-ins. Median time of door-to-CT read by neurologist were 17 IQR 11-24, CT read by neurologist-to-needle 58 IQR 42-83, and reversal order-to-needle 37 IQR 27-52 minutes. The strongest predictor of faster DTR times was treatment under a SA protocol, with adjusted mean DTR for SA 76 95% CI 1-155 versus 179 95% CI 111-247 minutes for non-SA (p <0.001) patients. Conclusions: Similar to the acute ischemic stroke treatment timeline, reversal of anticoagulation in AA-ICrH was significantly faster when using a SA protocol, underscoring the critical role of streamlined emergency pathways using SA to improve DTR times. These observations highlight the need for targeted interventions to reduce delays and leverage the rapid onset of action of the approved reversal agents.