Management and Prognostic Features of Intracerebral Hemorrhage During Anticoagulant Therapy: A Swedish Multicenter Study

Background and Purpose-Patients treated with oral anticoagulants (ACs) have an increased risk of intracerebral hemorrhage (ICH), which is more often fatal than spontaneous ICH. Options to reverse the AC effect include intravenous administration of vitamin K, plasma, and coagulation factor concentrate. However, the optimal management of AC-related ICH has not been determined in any randomized trial. In this study, the present management of AC-related ICH was surveyed, and determinants of survival were assessed. Methods-We retrospectively reviewed the medical records of all AC-related ICHs at 10 Swedish hospitals during a 4-year period, 1993 to 1996. Survival status after the ICH was determined from the Swedish National population register. Results-We identified 151 patients with AC-related ICH. Death rates were 53.6% at 30 days, 63.6% at 6 months, and 77.5% at follow-up (mean 3.5 years). The case fatality ratio at 30 days was 96% among patients unconscious on admission (n27), 80% among patients who became unconscious before active treatment was started (n15), 55% among patients in whom no special action was taken except withdrawal of AC treatment (n42), and 28% among patients given active anti-coumarin treatment while they were still conscious (n64). The case fatality ratio at 30 days was 11% in the group treated with plasma (n18), 30% in the group treated with vitamin K (n23), and 39% in the group treated with coagulation factor concentrate (n23). Within the first 24 to 48 hours after admission, 47% of the patients deteriorated. Choice of therapy to reverse the AC effect differed substantially between the hospitals (P0.0001), as did the time interval from symptom onset to start of treatment. Multiple logistic regression analysis showed only 2 factors (intraventricular extension of bleeding and ICH volume) that were independently related to case fatality at both 30 days and 6 months. The results were similar when the analysis was restricted to patients who were conscious on admission. Conclusions-In AC-related ICH, a progressive neurological deterioration during the first 24 to 48 hours after admission is frequent, and the mortality is high. Choice of therapy to reverse the AC effect differed considerably between the hospitals. There was no evidence that any treatment strategy was superior to the others. A randomized controlled trial is needed to determine the best choice of treatment. (Stroke. 2001;32:2567-2574.) Key Words: anticoagulants cerebral hemorrhage prognosis tomography, x-ray computed T he use of oral anticoagulant (AC) treatment has increased significantly in Sweden during recent years. Currently, 0.8% of the Swedish population has been estimated to receive such therapy. 1 AC treatment increases the risk of intracerebral hemorrhage (ICH) 8-to 10-fold. 2,3 Among patients given AC treatment during longer periods, the annual risk of ICH is 1% to 2%. 4] ajor textbooks published in the early 1990s and a recently published authorized guideline provide either no specific recommendations of pharmacological treatment of AC-related ICH in the acute phase, Administration of