Clinical short communication
The prognostic utility of ICH-score in anticoagulant related intracerebral hemorrhage

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Highlights

  • Intracranial hemorrhage (ICH) score is used to estimate the probability of mortality following spontaneous ICH of any cause.

  • We explored the utility in patients under vitamin K antagonists (VKA-ICH) or non-vitamin K oral anticoagulants (NOAC-ICH).

  • ICH score can adequately predict 30-day mortality for ICH patients with history of oral anticoagulant intake.

  • The score seems to have a better prognostic yield for NOAC-ICH compared to VKA-ICH.

Abstract

Although intracerebral hemorrhage (ICH) score is used to provide an estimate on the probability of mortality following spontaneous ICH of any cause, its utility has not been exclusively tested in ICH patients with history of treatment with vitamin K antagonists (VKAs) or non-vitamin K oral anticoagulants (NOACs). The aim of the present report is to investigate the utility of ICH score for mortality prognostication of VKA-ICH and NOAC-ICH patients. We used receiver operating characteristic curve analyses to estimate the accuracy parameters for the different values of ICH score in the prognosis of mortality within 30-days after the onset of NOAC-ICH or VKA-ICH.

We analyzed data from 108 NOAC-ICH and 241 VKA-ICH patients (median age 76 years, 58% males, median NIHSS score 11 points, median ICH-score 2 points). ICH score of 4 points was uncovered to be the most favorable threshold for the prediction of 30-day mortality both after NOAC-ICH (sensitivity: 57.7%, specificity: 98.8%) or VKA-ICH (sensitivity: 42.1%, specificity: 92.6%). However, comparison of the areas under the curve (AUC) suggested a cumulatively higher (p = .001) predictive value of ICH-score in the prognostication of 30-day mortality after ICH related to the use of NOACs (AUC: 0.92, 95%CI: 0.86–0.98) compared to the ICH related to the use of VKAs (AUC: 0.77, 95%CI: 0.70–0.83). In conclusion, ICH score seems to have an adequate predictive utility in the prognostication of 30-day mortality following an ICH related to the use of oral anticoagulants, with better yield in ICH cases associated with the use of NOACs.

Introduction

Even though the intracerebral hemorrhage (ICH) score provides a valid clinical grading scale that allows stratification on the probability of 30-day mortality for patients with ICH [1,2], this score has not been sufficiently validated in patients with ICH related to the use of oral anticoagulants (OAC-ICH), which are known to have a significantly higher mortality risk compared to ICH patients without history of OAC treatment [3]. A very recent systematic review and meta-analysis highlighted significant inconsistency in the prognostic utility of ICH-score between validation cohorts, suggesting that mortality is dependent on factors not included in the current version of the ICH score [4]. Anticoagulation is a predictor of hematoma expansion and mortality followiing ICH, but these risk are not uniform amongst different oral anticoagulants.

Taking into account that patients with ICH related to the use of non-vitamin K antagonist oral anticoagulants (NOAC-ICH) have smaller baseline hematoma volumes and less severe stroke syndromes compared to patients with ICH related to the use of vitamin K antagonists (VKA-ICH) [5], we sought to compare the performance of ICH score in the prognostication of 30-day mortality in NOAC-ICH and VKA-ICH.

Section snippets

Methods

We performed a post-hoc analysis of two prospective, international, multicenter, cohort studies of consecutive adult (≥18 years) patients with acute non-traumatic OAC-ICH. These cohorts are described in detail elsewhere [6,7]. In brief, VKA-ICH patients were required to be on current treatment with a VKA regiment and present on admission with an international normalized ratio (INR) value of >1.5, while NOAC-ICH patients should have confirmed intake of a NOAC the last 24 h before the ICH onset [6

Results

After excluding 8 patients with unavailable data on the exact time of death during follow-up, we included a total of 108 NOAC-ICH (dabigatran: 18, rivaroxaban: 47, apixaban: 43) and 241 VKA-ICH patients [median age: 76 years (IQR: 68–82), 58% men, median NIHSS score: 11 (4–21), median ICH-score: 2 (1–3)].

VKA-ICH patients had higher prevalence rates of chronic kidney disease (p = .006), increased neurological severity (p = .001) and more impaired consciousness on admission (p = .026) compared to

Discussion

Our study showed that ICH score can adequately predict 30-day mortality for ICH patients with history of oral anticoagulant intake, with possibly a more favorable yield for NOAC-ICH compared to VKA-ICH. Level of consciousness and ICH volume on admission emerged as two independent predictors of 30-day mortality in OAC-ICH on multivariable logistic regression models adjusting for potential confounders. Our observations are in line with a recent multicenter study reporting that the prognostic

Disclosures

None.

Acknowledgements

This work was partly presented as a Poster in the 5th European Stroke Organisation Conference, May 22-24, Milan, Italy.

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