Co-Author(s):
Robert Regenhardt, MD, PhD
Elif Gokcal, MD
Mitchell Horn, BSc
Nader Daoud, BA
Joshua Goldstein, MD, PhD
Anderson Christopher, MD
Patel Aman, MD
William Kimberly, MD, PhD
Viswanathan Anand, MD, PhD
lee Schwamm, MD
Jonathan Rosand, MD
Steven Greenberg, MD, PhD
Mahmut Gurol, MD
Massachusetts General Hospital
55 Fruit Street, Boston, MA 02114
Introduction | Objectives: Limited data exists on the predominant cerebral small vessel disease (CSVD) type underlying oral anticoagulant-related intracerebral hemorrhage (OAC-ICH), including non-vitamin K antagonist oral anticoagulant-related ICH (NOAC-ICH) and vitamin K antagonist-related intracerebral hemorrhage (VKA-ICH). Herein, we evaluated the two common types of CSVD, hypertensive-CSVD (HTN-CSVD) and cerebral amyloid angiopathy (CAA) in atrial fibrillation (AF) patients with NOAC-ICH and VKA-ICH.
Methods: In a prospective database of consecutive non-traumatic ICH patients admitted to a single referral center (April 2003 to December 2019), brain MRI scans were reviewed to diagnose probable CAA (using modified Boston criteria) or HTN-CSVD (the presence of a deep macrobleed with strictly deep or no microbleeds [MBs]). The frequency of additional magnetic resonance imaging (MRI) markers of high ICH risk including lacunes and cortical superficial siderosis (cSS) were also assessed.
Results: 1841 patients were included in this study, of which 398 (21.6%) had AF. In this cohort, 53 experienced a NOAC-ICH and 302 experienced a VKA-ICH. The in-hospital case fatality was 39.6% for NOAC-ICH and 47.0% for VKA-ICH, both higher than non-OAC-ICH (35.3%, p< 0.05 for both comparisons). The prevalence of HTN-cSVD was similar between NOAC-ICH and VKA-ICH (28.1% in NOAC-ICH and 27.8% in VKA-ICH, p = 0.97). Probable CAA was diagnosed in 28.1% of NOAC-ICH compared to 24.6% of VKA-ICH (p = 0.66). The frequency of lacunes, cSS, and MBs was also similar between groups. Moreover, 96.9% of patients with NOAC-ICH had at least one neuroimaging marker of high ICH risk compared to 86.4% of patients with sICH (p = 0.087).
Conclusions: CAA represents a substantial underlying pathology in both NOAC-ICH and VKA-ICH. As 97% of NOAC-ICH patients had high ICH risk markers on MRI: 1) patients without these markers are unlikely to have ICH while on NOACs, 2) nonpharmacological stroke prevention methods can be considered in the presence of these markers.