title: Vitamin K antagonist-associated intracerebral hemorrhage: lessons from a devastating disease in the dawn of the new oral anticoagulants.
abstract: BACKGROUND
  Intracerebral hemorrhage (ICH) is the most feared complication associated with vitamin K antagonists (VKAs). We performed a retrospective study on the clinicoradiologic characteristics that influence its outcome.
  
  
  METHODS
  We reviewed the clinical histories and neuroimaging studies of all patients attended at the Hospital Universitario Central de Asturias in 2010-2011 who had an ICH while being on VKA and analyzed the differential characteristics between patients with acceptable versus poor outcomes attending to 3 end points: death, poor outcome (modified Rankin Scale [mRS] score ≥ 4) at discharge, and poor outcome 3 months later. Additionally, CHA2DS2-VASc and HAS-BLED scores (validated tools for prediction of the risk of stroke and major hemorrhage, respectively, in patients with atrial fibrillation) were calculated to assess a priori risk-benefit balance for anticoagulant therapy.
  
  
  RESULTS
  Eighty patients entered the sample (median age of 79 years). A priori annual risk of major bleeding surpassed ischemic stroke risk-without anticoagulation-only in 4. Fifty percent of the patients had an initial Glasgow Coma Scale (GCS) score lower than 13; in 51.3%, initial international normalized ratio was above their therapeutic range. Median hematoma size was 24.75 cc(3); relevant growth (≥33%) occurred in 29.4% of patients with a second computed tomography scan. On multivariable analysis, overall in-hospital mortality (47.5%) was related to prior antiplatelet therapy (P = .008), GCS (P = .001), and perilesional edema size (P = .036). Baseline mRS (P = .058) and National Institutes of Health Stroke Scale (NIHSS) scores (P = .008) were associated with poor outcome at discharge (77.5%). Initial NIHSS (P = .005) and glycemia (P = .038) predicted 3-month poor outcome (68.3%). VKA reversal was performed in almost all patients, which prevented assessment of its therapeutic value.
  
  
  CONCLUSIONS
  VKA-associated ICH presents in a particularly vulnerable population and has a poor prognosis that may be reliably predicted by several clinicoradiologic features.
authors: Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain. Electronic address: mspin116125@hotmail.com.
authors: Marta
authors: M
authors: Suárez-Pinilla
authors: Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
authors: Ángeles
authors: Á
authors: Fernández-Rodríguez
authors: Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
authors: Lorena
authors: L
authors: Benavente-Fernández
authors: Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
authors: Sergio
authors: S
authors: Calleja-Puerta
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D001921:Brain / Q000473:pathology; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D019934:International Normalized Ratio; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000453:epidemiology / Q000401:mortality; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors*
chemical_list: D000925:Anticoagulants; D014812:Vitamin K
keywords: Intracerebral hemorrhage; anticoagulants; outcome; warfarin-associated intracerebral hemorrhage