Location and outcome of anticoagulant-associated intracerebral hemorrhage

Background: The characteristics of patients with anticoagulant-associated intracerebral hemorrhage (AAICH) have not been well characterized in a population-based setting. Methods: We attempted to ascertain all patients with ICH in Greater Cincinnati from May 1998 to July 2001 and August 2002 to April 2003 via retrospective review of ICD-9 codes 430-438.9 at all area hospitals and prospective surveillance at tertiary centers. Cases of ICH without coagulopathy and AAICH were compared with multivariate logistic modeling and survival analysis. Results: AAICH occurred in 190 of 1041 ICH cases (18%). In multivariate analysis, predictors of AAICH were cerebellar location of hemorrhage (p ≤ 0.01) and a history of coronary artery disease (p < 0.001), ischemic stroke (p < 0.001), atrial fibrillation (p < 0.001) and DVT or PE (p < 0.001). Relative to other ICH locations, only cerebellar ICH showed an excess risk of anticoagulant-associated hemorrhage (OR 2.2, 95% CI 1.2 to 4.0). In multivariate modeling the only predictor of cerebellar location of ICH was anticoagulation (p < 0.001). Patients with AAICH were more likely to die than other ICH patients. The difference in morality occurred by day one (mortality 33.2% vs 16.3%, p < 0.001) and remained stable through one year (mortality 66.3% vs 50.3%, p < 0.001). Conclusions: AAICH preferentially affects the cerebellum. Despite its association with amyloid angiopathy, lobar ICH was no more likely to be anticoagulant-associated than deep cerebral ICH. The excess mortality among AAICH patients accrues within one day of hemorrhage. Patients with AAICH have a high burden of vascular risk factors. New treatments for AAICH with prothrombotic potential should be evaluated in randomized controlled trials before routine use.