Anticoagulant Related Intracerebral Hemorrhage — Favorable Outcomes with Surgical Treatment
Abstract & Commentary
By Alan Z. Segal, MD, Assistant Professor, Department of Neurology, Weill-Cornell Medical College, Attending Neurologist, NewYork-Presbyterian Hospital. Dr. Segal is on the speaker's bureau for Boehringer-Ingelheim.
Synopsis: Selected patients with anticoagulation-associated intracerebral hemorrhage may benefit from surgical evacuation.
Source: Rabinstein AA, Wijdicks EF. Determinants of outcome in anticoagulation-associated cerebral hematoma requiring emergency evacuation. Arch Neurol. 2007;64:203-206.
As the population ages, atrial fibrillation has become even more prevalent. In this setting, over the past decade, use of warfarin for stroke prophylaxis has approximately quadrupled. At the same time, the incidence of intracerebral hemorrhage (ICH) has increased over 10 fold, particularly among patients over the age of 80. This group is at particular risk for ICH, at least in part due to underlying cerebral amyloid angiopathy (CAA), which is typically unrecognized until after an often-major incident hemorrhage.
Warfarin associated ICH is associated with a more ominous prognosis than sporadic ICH, with significant risk of hematoma expansion over the initial 24 hours of hospitalization. Immediate reversal of anticoagulation with Vitamin K and fresh frozen plasma is crucial. Recombinant activated Favor VIIa is now an alternative standard of care for anti-coagulant associated ICH and we are awaiting Phase III data regarding efficacy in any ICH case.
Rabinstein reports on 17 consecutive patients at the Mayo Clinic who underwent craniotomy for evacuation of ICH between the years of between 1977 and 2004. Hypertension affected over 70% of patients. Since there is significant overlap between HTN and CAA in this population, neither could be specifically identified as causal in Rabinstein's series. Mean hematoma volume was 75cc, with shift of midline structures in all patients. Functional outcome at one year was favorable in 11 (65%) of the patients (mRS ≤ 3). Five of 6 patients, who failed to recover meaningfully, died; all of these developed serious medical complications. Among those who died, 3 of 5 awoke within the first day after surgery but later had systemic complications. There was no difference in outcomes based on incidence of HTN, indication for anticoagulation, INR level, time to surgery, depth of coma, size of hematoma, or degree of shift. Patients with unfavorable outcomes were significantly older. All patients with a heparin-associated bleed (n = 4) had a favorable outcome.
Commentary
Despite multiple studies, there has been little data to support surgery for intracerebral hemorrhage. Surprisingly, in the current study of the most severe form of ICH, which associated with anticoagulants, surgical intervention produced a favorable outcome in a majority of cases. This was achieved despite huge hematoma volumes, well above the 60 ml cutoff associated with a poor prognosis in prior studies. Not surprisingly, advanced patient age was a negative prognostic factor and medical complications played a major role in mortality. With a lack of control patients, these data comprise a case series, rather than a comparative study. They do, however, indicate that an aggressive surgical approach, in concert with rapid reversal of coagulopathy, may be indicated for selected patients, who otherwise have a uniformly poor prognosis.
Selected patients with anticoagulation-associated intracerebral hemorrhage may benefit from surgical evacuation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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