Cardioembolic Stroke Risk and Recovery After Anticoagulation-Related Intracerebral Hemorrhage

Meredith P Murphy; Joji B Kuramatsu; Audrey Leasure; Guido J Falcone; Hooman Kamel; Lauren H Sansing; Christina Kourkoulis; Kristin Schwab; Jordan J Elm; M Edip Gurol; Huy Tran; Steven M Greenberg; Anand Viswanathan; Christopher D Anderson; Stefan Schwab; Jonathan Rosand; Fu-Dong Shi; Steven J Kittner; Fernando D Testai; Daniel Woo; Carl D Langefeld; Michael L James; Sebastian Koch; Hagen B Huttner; Alessandro Biffi; Kevin N Sheth

doi:10.1161/STROKEAHA.118.021799

Cardioembolic Stroke Risk and Recovery After Anticoagulation-Related Intracerebral Hemorrhage

Stroke. 2018 Nov;49(11):2652-2658. doi: 10.1161/STROKEAHA.118.021799.

Authors

Meredith P Murphy^{1

2

3}, Joji B Kuramatsu⁴, Audrey Leasure⁵, Guido J Falcone⁵, Hooman Kamel⁶, Lauren H Sansing⁵, Christina Kourkoulis^{1

2

3}, Kristin Schwab^{1

3}, Jordan J Elm⁷, M Edip Gurol^{1

3}, Huy Tran⁸, Steven M Greenberg^{1

3}, Anand Viswanathan^{1

3}, Christopher D Anderson^{1

2

3}, Stefan Schwab⁴, Jonathan Rosand^{1

2

3}, Fu-Dong Shi⁹, Steven J Kittner¹⁰, Fernando D Testai¹¹, Daniel Woo¹², Carl D Langefeld¹³, Michael L James¹⁴, Sebastian Koch¹⁵, Hagen B Huttner⁴, Alessandro Biffi^{1

2

3}, Kevin N Sheth⁵

Affiliations

¹ From the Department of Neurology, Massachusetts General Hospital, Boston (M.P.M., C.K., K.S., M.E.G., S.M.G., A.V., C.D.A., J.R., A.B.).
² Center for Genomic Medicine, Massachusetts General Hospital (MGH), Boston (M.P.M., C.K., C.D.A., J.R., A.B.).
³ Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, MGH, Boston, MA (M.P.M., C.K., K.S., M.E.G., S.M.G., A.V., C.D.A., J.R., A.B.).
⁴ Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (J.B.K., S.S., H.B.H.).
⁵ Divisions of Neurocritical Care & Emergency Neurology and Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (A.L., G.J.F., L.H.S., K.N.S.).
⁶ Department of Neurology, Weill Cornell College of Medicine, New York, NY (H.K.).
⁷ Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.J.E.).
⁸ Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque (H.T.).
⁹ Department of Neurology, Barrow Neurological Institute, Phoenix, AZ (F.-D.S.).
¹⁰ Department of Neurology, Baltimore VA Medical Center, University of Maryland School of Medicine, Baltimore (S.J.K.).
¹¹ Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago (F.D.T.).
¹² Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (D.W.).
¹³ Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.L.).
¹⁴ Department of Anesthesiology, Duke University, Durham, NC (M.L.J.).
¹⁵ Baltimore Veterans Administration Medical Center, University of Maryland, Baltimore (S.K.).

Abstract

Background and Purpose- Whether to resume oral anticoagulation treatment after intracerebral hemorrhage (ICH) remains an unresolved question. Previous studies focused primarily on recurrent stroke after ICH. We sought to investigate the association between cardioembolic stroke risk, oral anticoagulation therapy resumption, and functional recovery among ICH survivors in the absence of recurrent stroke. Methods- We conducted a joint analysis of 3 observational studies: (1) the multicenter RETRACE study (German-Wide Multicenter Analysis of Oral Anticoagulation Associated Intracerebral Hemorrhage); (2) the Massachusetts General Hospital ICH study (n=166); and (3) the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage; n=131). We included 941 survivors of ICH in the setting of active oral anticoagulation therapy for prevention of cardioembolic stroke because of nonvalvular atrial fibrillation and without evidence of ischemic stroke and recurrent ICH at 1 year from the index event. We created univariable and multivariable models to explore associations between cardioembolic stroke risk (based on CHA₂DS₂-VASc scores) and functional recovery after ICH, defined as achieving modified Rankin Scale score of ≤3 at 1 year for participants with modified Rankin Scale score of >3 at discharge. Results- In multivariable analyses, the CHA₂DS₂-VASc score was associated with a decreased likelihood of functional recovery (odds ratio, 0.83 per 1 point increase; 95% CI, 0.79-0.86) at 1 year. Anticoagulation resumption was independently associated with a higher likelihood of recovery, regardless of CHA₂DS₂-VASc score (odds ratio, 1.89; 95% CI, 1.32-2.70). We found an interaction between CHA₂DS₂-VASc score and anticoagulation resumption in terms of association with increased likelihood of functional recovery (interaction P=0.011). Conclusions- Increasing cardioembolic stroke risk is associated with a decreased likelihood of functional recovery at 1 year after ICH, but this association was weaker among participants resuming oral anticoagulation therapy. These findings support, including recovery metrics, in future studies of anticoagulation resumption after ICH.

Keywords: anticoagulation; atrial fibrillation; hemorrhage; mortality; risk; stroke.

Publication types

Observational Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Anticoagulants / adverse effects*
Anticoagulants / therapeutic use
Atrial Fibrillation / complications
Atrial Fibrillation / drug therapy*
Cerebral Hemorrhage / chemically induced*
Female
Humans
Intracranial Embolism / epidemiology*
Intracranial Embolism / etiology
Intracranial Embolism / prevention & control
Logistic Models
Male
Middle Aged
Multivariate Analysis
Recovery of Function
Risk Assessment
Stroke / epidemiology*
Stroke / etiology
Stroke / prevention & control

Substances

Anticoagulants

Abstract

Publication types

MeSH terms

Substances

Grants and funding