Evaluating an Optimal Time to Anticoagulant Reversal in Intracerebral Hemorrhage

Abstract

Abstract Background: The utilization of long-term oral anticoagulation is steadily expanding due to the growing number of patients diagnosed with thromboembolic diseases, such as atrial fibrillation or venous thromboembolism. Anticoagulation use can exacerbate hematoma expansion and increase intracerebral hemorrhage (ICH) volume resulting in high mortality and severe morbidity. However, unlike the treatment of ischemic stroke, the optimal time to reversal for hemorrhagic stroke is not clearly defined in the guidelines. Observational studies have evaluated the effect of time to reversal administration and have shown improvement on inpatient mortality and hematoma enlargement. The objective of this study was to evaluate the change in functional outcomes for intracerebral hemorrhage patients who received anticoagulant reversal within 90 minutes of presentation. Methods: This retrospective, observational cohort study included anticoagulated adult patients diagnosed with an intracerebral hemorrhage on a computerized tomography scan who received anticoagulant reversal at Northeast Georgia Medical Center between January 1, 2018 – September 30, 2022. Patients were excluded if diagnosed with an aneurysm, another bleed, or administered desmopressin. The primary outcome was to evaluate the change in functional outcomes for ICH patients who received anticoagulant reversal within 90 minutes of presentation. Secondary outcomes included the change in functional outcomes for ICH patients who received anticoagulation reversal within 30 or 60 minutes of presentation, time to international normalized ratio (INR) normalization if on warfarin, and to assess the incidence of thrombotic and rebleed events after reversal. Results: Sixty-one patients met inclusion criteria with thirty-six patients receiving reversal within 90 minutes and twenty-five receiving reversal after 90 minutes of arrival. Baseline characteristics were similar between groups. Overall, there was no change in functional outcomes for patients who received anticoagulation reversal within 90 minutes (75% vs. 52%, p=0.07); 60 minutes (71% vs. 63%, p=0.49) or 30 minutes of arrival (100% vs. 64%, p=0.3) compared to after these time points. There was a similar incidence of rebleed (3% vs. 4%) and thrombotic events (6% vs. 0%) between groups. Conclusion: Functional outcomes were similar for intracerebral hemorrhage patients who received anticoagulation reversal within 90 minutes compared to those who received it after 90 minutes of Emergency Department arrival.