Introduction: Intracerebral hemorrhage (ICH) is a devastating disease that accounts for 10-15% of strokes with the highest morbidity and mortality of all stroke subtypes. ICH is commonly complicated by coagulopathy, often leading to poorer outcomes. Coagulopathy-associated ICH can be caused by an underlying pathology (e.g. hemophilia) or anticoagulant medication (e.g. warfarin). As a result, current guidelines for management of ICH patients with coagulopathies, anticoagulant-associated and congenital, involve a combination of withdrawal of the anticoagulant agent and administration of the appropriate replacement factor. Despite a standard of care meant to reverse these pathologies, there have been no recent large-scale studies assessing outcomes of ICH patients with pathological coagulopathies.
Methods: The American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) data set was queried for International Classification of Disease, 9th Revision (ICD-9) diagnosis code 851.8 to isolate cases of ICH for the years 2010 through 2015. Descriptive statistics were run to characterize patients with a noted bleeding disorder compared to those without a coagulopathy. Univariate analysis using chi-square and Student's t-tests were used to assess outcomes and multivariable regression analyses were run to compare outcomes while controlling for relevant comorbidities and demographics.
Results: 1687 patients with an ICH were identified, 96 of whom had a bleeding disorder. Univariate analysis without risk adjustment demonstrated that patients with bleeding disorders had a higher mortality rate (10.4% vs. 4.9% p=0.018) with no significant difference in overall complication rates (33.3% vs. 39.9% p=0.20). However, multivariable regression analysis demonstrated that bleeding disorders were not an independent risk factor for death (Odds Ratio (OR)=1.565 [0.715-3.424] p-value=0.26) or complication (OR=1.619 [0.934-2.803] p=0.086).
Conclusions: Our results suggest that current methods for reversing coagulopathy work effectively insofar as mitigating adverse effects of the coagulopathy itself as seen by the similar outcomes among ICH patients.
Patient Care: This study offers insights into the effectiveness of current treatment methods for ICH patients with coagulopathies.
Learning Objectives: By the conclusion of this session, participants should be able to 1) describe the purpose of the study 2) discuss how coagulopathy affect traumatic ICH outcomes 3) understand the implications of the results.
References: 1. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral hemorrhage. Lancet. 2009;373:1632–1644. doi: 10.1016/S0140-6736(09)60371-8.
2. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Flibotte JJ, Hagan N, O'Donnell J, Greenberg SM, Rosand J Neurology. 2004 Sep 28; 63(6):1059-64.
3. Flaherty ML, Kissela B, Woo D, Kleindorfer D, Alwell K, Sekar P, Moomaw CJ, Haverbusch M, Broderick JP. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology. 2007;68:116–121.
4. Hemphill, J. C., III, Greenberg, S. M., Anderson, C. S., Becker, K., Bendok, B. R., Cushman, M., et al. (2015). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke, 46(7), 2032–2060.