Findings may help with the management of anticoagulant-related bleeding within the brain

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Among patients with oral anticoagulation-associated intracerebral haemorrhage, reversal of international normalised ratio (INR) below a certain level within four hours and systolic blood pressure less than 160mmHg at four hours were associated with lower rates of enlargement, and resumption of anticoagulant therapy was associated with a lower risk of ischaemic events without increased bleeding complications, according to a study in JAMA.

The prevalence of cardiovascular diseases requiring long-term oral anticoagulation is increasing. The most significant complication of this is intracerebral haemorrhage. Among all types of stroke, there is a substantial lack of data about how to manage this complication. Two of the most pressing unsettled questions are how to prevent haematoma enlargement and how to manage anticoagulation in the long-term. Consensus exists that elevated INR levels should be reversed to minimise haematoma enlargement, yet mode of reversal, timing, and extent of INR reversal are unclear. Valid data on safety and clinical benefit of oral anticoagulation resumption are missing and remain to be established, according to background information in the article.

Hagen B Huttner, of the University of Erlangen-Nuremberg, Erlangen, Germany, and colleagues conducted a study to assess the association of anticoagulation reversal and blood pressure with haematoma enlargement and the effects of oral anticoagulation resumption. The study, conducted at 19 German tertiary care centres (2006-2012), included 1,176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of oral anticoagulation resumption.

Haemorrhage enlargement occurred in 307 of 853 patients (36%). Reduced rates of haematoma enlargement were associated with reversal of INR levels <1.3 within four hours after admission (43/217; 19.8%) vs INR of ≥1.3 (264/636; 41.5%) and systolic blood pressure <160mmHg at four hours (167/504; 33.1%) vs ≥160mmHg (98/187; 52.4%).The combination of INR reversal <1.3 within four hours and systolic blood pressure of <160mmHg at four hours was associated with lower rates of haematoma enlargement (18.1% vs. 44.2% not achieving these values) and lower rates of in-hospital death (13.5% vs 20.7%).

Oral anticoagulation was resumed in 172 of 719 survivors (23.9%), while resumption showed fewer ischaemic complications (5.2% vs no oral anticoagulation 15%) and not significantly different haemorrhagic complications (8.1% vs no oral anticoagulation, 6.6%).

“The study represents the largest cohort of patients with OAC­ICH to date and reports two clinically valuable associations. First, rates of haematoma enlargement were decreased in patients with INR values reversed below 1.3 within four hours of admission and systolic blood pressures of less than 160mmHg at four hours. Second, rates of ischaemic events were decreased among patients who restarted oral anticoagulation without increased rates of bleeding complications,” the authors write.

“These retrospective findings require replication and assessment in prospective studies.”