A multicenter, prospective, observational study of warfarin-associated intracerebral hemorrhage: The SAMURAI-WAICH study.

Abstract

BACKGROUND:

Because patients with warfarin-associated intracerebral hemorrhage (WAICH) have a high risk of ongoing bleeding, disability, and death, urgent coagulopathy reversal should be considered. On the other hand, thromboembolism may occur with reversal or withholding of anticoagulant therapy. The current status of acute hemostatic treatments and clinical outcomes in WAICH patients was investigated.

METHODS:

WAICH patients admitted within 3 days of onset were prospectively enrolled in 10 stroke centers. Thromboembolic and hemorrhagic complications and functional outcomes were followed-up for one year.

RESULTS:

Of 50 WAICH patients (31 men, 73 ± 9 years old) enrolled, all stopped warfarin on admission. Elevated prothrombin time-international normalized ratios (PT-INR) were normalized in 43 (86%). Anticoagulant therapy was resumed with intravenous full-dose unfractionated heparin followed by warfarin in 9 (18%), intravenous low-dose unfractionated heparin followed by warfarin in 14 (28%) and warfarin alone in 14 (28%) at a median of 2.5 (IQR 1.25-9), 4 (2-5.5) and 6 (3-11) days after onset, respectively, after emergent admission. Onset-to-admission time (per 1-hour increase; OR 0.55, 95% CI 0.19-0.84) was inversely associated with hematoma expansion. Anticoagulant therapy was resumed with intravenous full-dose unfractionated heparin in 9 (18%), low-dose heparin in 14 (28%) and warfarin alone in 14 (28%) at a median of 2.5, 4 and 6 days after onset, respectively. During one-year follow-up (n=47), 11 thromboembolic and 6 hemorrhagic complications were documented. Twenty four patients showed unfavorable outcomes, corresponding to a modified Rankin Scale score of 4-6. Thromboembolic complications (OR, 10.62; 95% CI, 1.05-227.85), as well as advanced age (per 1 year; OR, 1.27; 95% CI, 1.10-1.61) and higher National Institutes of Health Stroke Scale (NIHSS) score (per 1 point; OR, 1.24; 95% CI 1.07-1.55), were independently associated with unfavorable outcome.

CONCLUSIONS:

PT-INR normalization on admission and early anticoagulant resumption were common in WAICH patients. Thromboembolic complications were independently associated with unfavorable outcome.

• Authors: Masato Osaki, Masatoshi Koga, Koichiro Maeda, Yasuhiro Hasegawa, Jyoji Nakagawara, Eisuke Furui, Kenichi Todo, Kazumi Kimura, Yoshiaki Shiokawa, Yasushi Okada, Satoshi Okuda, Kazuomi Kario, Hiroshi Yamagami, Kazuo Minematsu, Takanari Kitazono, Kazunori Toyoda, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement Study Investigators
• Journal: Journal of the neurological sciences (J Neurol Sci) Vol. 359 Issue 1-2 Pg. 72-7 (Dec 15 2015) ISSN: 1878-5883 [Electronic] Netherlands
• PMID: 26671089 (Publication Type: Clinical Trial, Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2015 Elsevier B.V. All rights reserved.

Chemical References

• Anticoagulants
• Warfarin

Topics

• Aged
• Aged, 80 and over
• Anticoagulants (therapeutic use)
• Cerebral Hemorrhage (complications, drug therapy)
• Cohort Studies
• Female
• Hematoma (etiology)
• Humans
• Male
• Middle Aged
• Observation
• Tomography, X-Ray Computed
• Treatment Outcome
• Warfarin (therapeutic use)